Provider Demographics
NPI:1982964565
Name:BLACKWELL, CHRISTOPHER (CNP)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:
Last Name:BLACKWELL
Suffix:
Gender:M
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 BALL AVE
Mailing Address - Street 2:
Mailing Address - City:TYLERTOWN
Mailing Address - State:MS
Mailing Address - Zip Code:39667-2101
Mailing Address - Country:US
Mailing Address - Phone:601-377-1975
Mailing Address - Fax:601-377-1976
Practice Address - Street 1:107 BALL AVE
Practice Address - Street 2:
Practice Address - City:TYLERTOWN
Practice Address - State:MS
Practice Address - Zip Code:39667-2101
Practice Address - Country:US
Practice Address - Phone:601-377-1975
Practice Address - Fax:601-377-1976
Is Sole Proprietor?:No
Enumeration Date:2012-05-17
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR871872363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS103I507204OtherMEDICARE PTAN
MS01538051Medicaid
MS9365915OtherAETNA
MS937501OtherWINDSOR
MSP01087211OtherRAILROAD MEDICARE