1558934364 NPI number — DESTINEE D BLACKWELL-CLARY LPN

Table of content: DESTINEE D BLACKWELL-CLARY LPN (NPI 1558934364)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558934364 NPI number — DESTINEE D BLACKWELL-CLARY LPN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLACKWELL-CLARY
Provider First Name:
DESTINEE
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BLACKWELL
Provider Other First Name:
DESTINEE
Provider Other Middle Name:
D
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1558934364
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/19/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 188
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHILLICOTHEE
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45601-0188
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
740-773-4366
Provider Business Mailing Address Fax Number:
740-773-4750

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8978 UNITED LN STE 102
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ATHENS
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45701-3668
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
740-274-4246
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/20/2021

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: 164W00000X , with the licence number:  LPN.177387.MEDS-IV , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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