Provider Demographics
NPI:1063289635
Name:BLACKWELL, CLYDIE (RN)
Entity type:Individual
Prefix:
First Name:CLYDIE
Middle Name:
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:329 N 81ST ST
Mailing Address - Street 2:
Mailing Address - City:CAHOKIA HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:62203-2509
Mailing Address - Country:US
Mailing Address - Phone:770-896-0187
Mailing Address - Fax:
Practice Address - Street 1:505 S 8TH ST
Practice Address - Street 2:
Practice Address - City:EAST SAINT LOUIS
Practice Address - State:IL
Practice Address - Zip Code:62201-2919
Practice Address - Country:US
Practice Address - Phone:618-474-7330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-05
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041165940163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)