Provider Demographics
NPI:1912727496
Name:BLACKETT, LAURA KIANE (FNP)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:KIANE
Last Name:BLACKETT
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 1:3450 HIDDEN MEADOW CIR
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN GREEN
Mailing Address - State:UT
Mailing Address - Zip Code:84050-6743
Mailing Address - Country:US
Mailing Address - Phone:801-645-0671
Mailing Address - Fax:
Practice Address - Street 1:1525 E 6000 S
Practice Address - Street 2:
Practice Address - City:SOUTH OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-7144
Practice Address - Country:US
Practice Address - Phone:801-337-5800
Practice Address - Fax:801-337-5809
Is Sole Proprietor?:No
Enumeration Date:2024-10-10
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT377805-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily