Provider Demographics
NPI:1194414292
Name:BLACKWELL, RAYA
Entity type:Individual
Prefix:
First Name:RAYA
Middle Name:
Last Name:BLACKWELL
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 1:1116 BLUE GARDEN DR
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720-6541
Mailing Address - Country:US
Mailing Address - Phone:205-914-1264
Mailing Address - Fax:
Practice Address - Street 1:1590 S SR 15A STE 100
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-7817
Practice Address - Country:US
Practice Address - Phone:386-774-0016
Practice Address - Fax:386-774-0606
Is Sole Proprietor?:No
Enumeration Date:2023-05-04
Last Update Date:2025-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical