KELLY COSTELLO BLACKMON (NPI# 1992110688) is a health care provider registered in Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES).
| Nation Provider ID (NPI) | 1992110688 |
| Entity Type | Individual |
| Full Name | KELLY COSTELLO BLACKMON |
| Credential | APRN |
| Practice Address |
2409 N. Patterson Street Suite 230 Valdosta GA 31602-2512 |
| Mailing Address |
Po Box 0070 Valdosta GA 31603-0070 |
| Practice Telephone | 2292594369 |
| Practice Fax Number | 2294336513 |
| Mailing Telephone | 2292594369 |
| Mailing Fax Number | 2294336513 |
| Enumeration Date | 2014-06-22 |
| Last Update Date | 2015-04-07 |
| Gender Code | F |
| Is Sole Proprietor | N |
| Primary | Taxonomy Code | Classification | License Number | License State | Taxonomy Group |
|---|---|---|---|---|---|
| Y | 363LA2100X |
Nurse Practitioner Specialization: Acute Care |
RN124057 | GA | Physician Assistants & Advanced Practice Nursing Providers |
| State | Issuer | Identifier | Type Code |
|---|---|---|---|
| GA | 003154267A | 05 |
| Street Address |
2409 N. PATTERSON STREET SUITE 230 |
| City | VALDOSTA |
| State | GA |
| Zip Code | 31602-2512 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1477198117 | Amber Michele Baugh | Behavior Technician | 2236 Bemiss Road, Valdosta, GA 31602 | 2019-11-15 |
| 1528611365 | Nishaben T. Patel | Nurse Practitioner | 3120 North Oak Street Extension, Suite B, Valdosta, GA 31602 | 2019-07-22 |
| 1427615871 | Blair Elizabeth Tomlinson | Nurse Practitioner | 2124 Lakeshore Drive, Valdosta, GA 31602 | 2019-05-21 |
| 1346704152 | Mildred Itaska Borowski | Counselor | 3790 North Highway 41, Suite A, Valdosta, GA 31602 | 2019-01-25 |
| 1962991703 | Southern Healthcare Alliance, LLC | Physical Medicine & Rehabilitation | 101-f W. Northside Drive, Valdosta, GA 31602 | 2018-05-08 |
| 1336636646 | Kaitlyn Thrift | Behavioral Analyst | 2225 Bemiss Road Suite D, Valdosta, GA 31602 | 2018-04-23 |
| 1407379845 | Lindsey Marie Richardson | Dentist | 103 W. Cranford Ave, Valdosta, GA 31602 | 2017-07-18 |
| 1962922427 | Taylor Nicole Fiveash | Nurse Practitioner | 101 W Northisde Dr, Bldg G, Valdosta, GA 31602 | 2017-06-26 |
| 1720520646 | Southern Sleepers Anesthesia LLC | Nurse Anesthetist, Certified Registered | 4120-b N. Valdosta Road, Valdosta, GA 31602 | 2016-11-09 |
| 1134670557 | Cataract and Laser Surgery Center of South Georgia, P.C. | Clinic/Center | 4120-b N. Valdosta Rd., Valdosta, GA 31602 | 2016-10-20 |
| Find all providers in zip 31602 | ||||
| Taxonomy Code | 363LA2100X |
| Grouping | Physician Assistants & Advanced Practice Nursing Providers |
| Classification | Nurse Practitioner |
| Specialization | Acute Care |
| Definition to come... |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1700410602 | Danielle C Yund | Nurse Practitioner | 2501 N Patterson St, Valdosta, GA 31602-1735 | 2020-02-28 |
| 1467936179 | Brooke Sukalski | Nurse Practitioner | 2409 N Patterson St, Valdosta, GA 31602-2512 | 2018-09-18 |
| 1003104670 | John Stephen Dodd | Nurse Practitioner | 2501 N Patterson St, Valdosta, GA 31602-1735 | 2011-07-18 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1265032114 | Candace Buckley | Nurse Practitioner | 244 Ashland Dr, Woodstock, GA 30189-7161 | 2020-10-29 |
| 1679170740 | Jennifer Lassiter | Nurse Practitioner | 4116 Holley Rd., Lizella, GA 31052 | 2020-10-02 |
| 1891301164 | Tashoy Wallace | Nurse Practitioner | 121 Odyssey Turn, Conyers, GA 30012-3681 | 2020-09-21 |
| 1912513672 | Katherine Anne Sego | Nurse Practitioner | 4060 Rolling Meadows Ln, Watkinsville, GA 30677-3011 | 2020-09-18 |
| 1548872468 | Phyllis Kelly Wood | Nurse Practitioner | 217 Banks Rd, Suite 31, Fayetteville, GA 30214 | 2020-08-21 |
| 1588276505 | Sherron Johnson | Nurse Practitioner | 1980 Wrights Way, Jonesboro, GA 30236-7205 | 2020-08-20 |
| 1942811682 | Ashlee Renee Mack | Nurse Practitioner | 116 Slate Cir, Savannah, GA 31419-9681 | 2020-08-16 |
| 1467063610 | Rosa Maria Phillips | Nurse Practitioner | 649 Amicalola Woods Rd, Dawsonville, GA 30534-1205 | 2020-08-12 |
| 1508476581 | Jarvis Reese | Nurse Practitioner | 413 Tug Ct, Warner Robins, GA 31088-2134 | 2020-08-05 |
| 1750991790 | Akosua Frema Sarfo | Nurse Practitioner | 116 Ginkgo Ln, Grovetown, GA 30813-5392 | 2020-08-04 |
| Find all providers with the same taxonomy | ||||
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| Data Provider | Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES) |
| Jurisdiction | Medicare & Medicaid |
This dataset includes 5.44 million covered health care providers and all health plans and health care clearinghouses, registered with CMA NPPES. Each provider is registered with National Provider Identifier (NPI), full name, status, address, taxonomy, other identifiers, etc.