Provider Demographics
NPI:1225878028
Name:BLACKWELL-HAFNER, REBECCA (MSN, FNP-BC)
Entity type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:
Last Name:BLACKWELL-HAFNER
Suffix:
Gender:F
Credentials:MSN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 W CHESTER ST
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401-5925
Mailing Address - Country:US
Mailing Address - Phone:347-210-8480
Mailing Address - Fax:
Practice Address - Street 1:334 PLAZA RD
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401-2975
Practice Address - Country:US
Practice Address - Phone:453-380-1808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-29
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY530634363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty