Provider Demographics
NPI:1689420424
Name:BLACKMON, LEASA LASAE (RN)
Entity type:Individual
Prefix:
First Name:LEASA
Middle Name:LASAE
Last Name:BLACKMON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 490182
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30049-0004
Mailing Address - Country:US
Mailing Address - Phone:470-232-5119
Mailing Address - Fax:
Practice Address - Street 1:240 MITCHELL BRIDGE RD
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-2043
Practice Address - Country:US
Practice Address - Phone:770-910-9196
Practice Address - Fax:678-682-8747
Is Sole Proprietor?:No
Enumeration Date:2024-04-24
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA221219163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health