Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 2081S0010X | Sports Medicine | 05014209A | IN |
N | 213ES0000X | Sports Medicine | 05014209A | IN |
Y | 225100000X | Physical Therapist | 05014209A | IN |
NPI | 1265002620 |
---|---|
Provider Name | Hannah Brooke Blystone |
First Address | Fort Wayne, IN 46845-1701 |
Second Address | Fort Wayne, IN 46805-1018 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/06/2021 |
Last Update Date | 19/07/2021 |