Individual
MICHAELA ROSE BLACKWELL
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
5875 E RIVERSIDE BLVD, ROCKFORD, IL 61114-4937
(815) 398-9491
Mailing address
PO BOX 735263, CHICAGO, IL 60673-5263
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
085010688
IL
Other
Enumeration date
02/14/2023
Last updated
11/01/2024
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