Provider Demographics
NPI:1386095891
Name:BLACKLEY, MONTANA N (CRNA)
Entity type:Individual
Prefix:
First Name:MONTANA
Middle Name:N
Last Name:BLACKLEY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7615 TRADITIONS AVE NE
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98516-1335
Mailing Address - Country:US
Mailing Address - Phone:503-703-7826
Mailing Address - Fax:
Practice Address - Street 1:209 LILLY RD NE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5030
Practice Address - Country:US
Practice Address - Phone:360-413-8250
Practice Address - Fax:360-413-8850
Is Sole Proprietor?:No
Enumeration Date:2016-06-27
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN201344163W00000X
TN22155367500000X
WAAP60877588367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse