Provider Demographics
NPI:1467288472
Name:BLAISDELL, ROBIN VANESSA
Entity type:Individual
Prefix:MRS
First Name:ROBIN
Middle Name:VANESSA
Last Name:BLAISDELL
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 1:6695 WHITE HAWK LN
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-7382
Mailing Address - Country:US
Mailing Address - Phone:662-782-6770
Mailing Address - Fax:
Practice Address - Street 1:214 W CENTER ST
Practice Address - Street 2:
Practice Address - City:HERNANDO
Practice Address - State:MS
Practice Address - Zip Code:38632-2242
Practice Address - Country:US
Practice Address - Phone:662-782-6770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-09
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS969225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist