Provider Demographics
NPI:1720808488
Name:BLACKMON, BEVERLY LOUISE
Entity type:Individual
Prefix:
First Name:BEVERLY
Middle Name:LOUISE
Last Name:BLACKMON
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 1:1171 HARDESTY BLVD
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44320-3562
Mailing Address - Country:US
Mailing Address - Phone:330-860-3542
Mailing Address - Fax:
Practice Address - Street 1:1171 HARDESTY BLVD
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44320-3562
Practice Address - Country:US
Practice Address - Phone:330-860-3542
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-16
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant