Provider Demographics
NPI:1336960350
Name:BLAKELY, LAWANDA
Entity type:Individual
Prefix:
First Name:LAWANDA
Middle Name:
Last Name:BLAKELY
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 1:260 FALL LEAF CIR
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99504-1590
Mailing Address - Country:US
Mailing Address - Phone:907-764-4119
Mailing Address - Fax:
Practice Address - Street 1:1709 BRAGAW ST
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-3436
Practice Address - Country:US
Practice Address - Phone:907-562-5340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-22
Last Update Date:2024-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker