Provider Demographics
NPI:1386270908
Name:BLACKBURN, BONNIE LYNN (PA)
Entity type:Individual
Prefix:MRS
First Name:BONNIE
Middle Name:LYNN
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 AMALIA DR
Mailing Address - Street 2:
Mailing Address - City:BUCKHANNON
Mailing Address - State:WV
Mailing Address - Zip Code:26201-2239
Mailing Address - Country:US
Mailing Address - Phone:304-473-2000
Mailing Address - Fax:
Practice Address - Street 1:10 AMALIA DR STE C5
Practice Address - Street 2:
Practice Address - City:BUCKHANNON
Practice Address - State:WV
Practice Address - Zip Code:26201-2270
Practice Address - Country:US
Practice Address - Phone:304-460-7948
Practice Address - Fax:304-460-7908
Is Sole Proprietor?:No
Enumeration Date:2020-03-15
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2411363AM0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program