Provider Demographics
NPI:1699086132
Name:BLACKBURN, SHELLY R
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:R
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1667 STONE RD LOT 3
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:OH
Mailing Address - Zip Code:45601-8211
Mailing Address - Country:US
Mailing Address - Phone:740-804-1642
Mailing Address - Fax:
Practice Address - Street 1:1667 STONE RD LOT 3
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:OH
Practice Address - Zip Code:45601-8211
Practice Address - Country:US
Practice Address - Phone:740-804-1642
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-30
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN252881163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse