Provider Demographics
NPI:1053692723
Name:BLACKBURN, ANGELIQUE
Entity type:Individual
Prefix:
First Name:ANGELIQUE
Middle Name:
Last Name:BLACKBURN
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 1:2470 ALADDIN LAMP ST
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89002-9375
Mailing Address - Country:US
Mailing Address - Phone:702-439-1677
Mailing Address - Fax:702-430-8288
Practice Address - Street 1:2470 ALADDIN LAMP ST
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89002-9375
Practice Address - Country:US
Practice Address - Phone:702-439-1677
Practice Address - Fax:702-430-8288
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-07
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker