Provider Demographics
NPI:1053422246
Name:BLACKWELL, TERESA LYNN (NP)
Entity type:Individual
Prefix:MS
First Name:TERESA
Middle Name:LYNN
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:TERESA
Other - Middle Name:BLACKWELL
Other - Last Name:MYERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:19124 SE 416TH ST
Mailing Address - Street 2:
Mailing Address - City:ENUMCLAW
Mailing Address - State:WA
Mailing Address - Zip Code:98022-9135
Mailing Address - Country:US
Mailing Address - Phone:360-802-4848
Mailing Address - Fax:
Practice Address - Street 1:3626 NE 45TH ST STE 300
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-5653
Practice Address - Country:US
Practice Address - Phone:206-526-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2016-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30007233363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care