Provider Demographics
NPI:1912700774
Name:BLACKFORD, BREANNA
Entity type:Individual
Prefix:
First Name:BREANNA
Middle Name:
Last Name:BLACKFORD
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 1:339 HARRISON AVE NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44708-4960
Mailing Address - Country:US
Mailing Address - Phone:614-648-8905
Mailing Address - Fax:
Practice Address - Street 1:339 HARRISON AVE NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44708-4960
Practice Address - Country:US
Practice Address - Phone:614-648-8905
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-28
Last Update Date:2025-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant