Individual
LISLE BLACKBOURN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
530 NE GLEN OAK AVE, PEORIA, IL 61637-0001
(309) 655-2000
Mailing address
N5884 PLANK RD, ELKHORN, WI 53121-4063
(608) 658-3642
Taxonomy
Speciality
Code
Description
License number
State
390200000X
Student in an Organized Health Care Education/Training Program
Primary
90200000X
IL
390200000X
Student in an Organized Health Care Education/Training Program
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Other
Enumeration date
03/24/2022
Last updated
03/24/2022
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