Provider Demographics
NPI:1396990164
Name:BLACKWELDER, LISA LALLIER (FNP)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:LALLIER
Last Name:BLACKWELDER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7610 N UNION BLVD STE 140
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-3894
Mailing Address - Country:US
Mailing Address - Phone:719-550-1172
Mailing Address - Fax:719-591-2864
Practice Address - Street 1:7610 N UNION BLVD STE 140
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-3894
Practice Address - Country:US
Practice Address - Phone:719-550-1172
Practice Address - Fax:719-591-2864
Is Sole Proprietor?:No
Enumeration Date:2008-11-20
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX579092363LF0000X
CO2022011328363LP0808X
COAPN.0992320-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX579092OtherFAMILY NURSE PRACTITIONER
CO9000191726Medicaid
TX75-2616977-028OtherTRICARE
TX7508181567022OtherTRICARE
TX070853903Medicaid
TX75-2616977-001OtherTRICARE
TX75-2616977-002OtherTRICARE
TXTXB135087Medicare Oscar/Certification