Provider Demographics
NPI:1104625201
Name:BLACKBEAR, LADONNA RENEE
Entity type:Individual
Prefix:
First Name:LADONNA
Middle Name:RENEE
Last Name:BLACKBEAR
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 W KEETOOWAH ST
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-3819
Mailing Address - Country:US
Mailing Address - Phone:918-931-3700
Mailing Address - Fax:
Practice Address - Street 1:113 W KEETOOWAH ST
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-3819
Practice Address - Country:US
Practice Address - Phone:918-931-3700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-11
Last Update Date:2025-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist