Provider Demographics
NPI:1063274843
Name:BLACKMON, QAYONNA NIKOLE
Entity type:Individual
Prefix:
First Name:QAYONNA
Middle Name:NIKOLE
Last Name:BLACKMON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 NEWBURG ST NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44709-1351
Mailing Address - Country:US
Mailing Address - Phone:330-612-6828
Mailing Address - Fax:
Practice Address - Street 1:1025 NEWBURG ST NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44709-1351
Practice Address - Country:US
Practice Address - Phone:330-612-6828
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-26
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide