Provider Demographics
NPI:1467257337
Name:BLACKBURN, ANGELA GONZALES (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:GONZALES
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3940 MOSS OAK DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32277-1325
Mailing Address - Country:US
Mailing Address - Phone:904-910-4688
Mailing Address - Fax:
Practice Address - Street 1:3940 MOSS OAK DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32277-1325
Practice Address - Country:US
Practice Address - Phone:904-910-4688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-15
Last Update Date:2025-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11037313363L00000X, 363LP0200X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics