1073630059 NPI number — MRS. CHERRON LAKISHA BLAKELY MT, CLS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073630059 NPI number — MRS. CHERRON LAKISHA BLAKELY MT, CLS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLAKELY
Provider First Name:
CHERRON
Provider Middle Name:
LAKISHA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MT, CLS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073630059
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
652 HATCHEE RIDGE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DUBLIN
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31021-0888
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
478-676-3081
Provider Business Mailing Address Fax Number:
478-277-2840

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1826 VETERANS BLVD
Provider Second Line Business Practice Location Address:
BLDG 3A, PATHOLOGY AND LABORATORY MEDICINE
Provider Business Practice Location Address City Name:
DUBLIN
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31021-3620
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
478-277-2750
Provider Business Practice Location Address Fax Number:
478-277-2840
Provider Enumeration Date:
03/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 246QM0706X , with the licence number:  219139 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 246QM0706X , with the licence number: 9909695 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)





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