Provider Demographics
NPI:1346518107
Name:BLACKBURN, KRISTINE (RN)
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 S 500 E
Mailing Address - Street 2:
Mailing Address - City:VERNAL
Mailing Address - State:UT
Mailing Address - Zip Code:84078-2728
Mailing Address - Country:US
Mailing Address - Phone:435-247-1177
Mailing Address - Fax:435-781-0538
Practice Address - Street 1:133 S 500 E
Practice Address - Street 2:
Practice Address - City:VERNAL
Practice Address - State:UT
Practice Address - Zip Code:84078-2728
Practice Address - Country:US
Practice Address - Phone:435-247-1177
Practice Address - Fax:435-781-0538
Is Sole Proprietor?:No
Enumeration Date:2011-12-08
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT277462-3102171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator