Provider Demographics
NPI:1043804354
Name:BLACKBURN, DONNA
Entity Type:Individual
Prefix:
First Name:DONNA
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 1:302 PETTIT HEIGHTS RD
Mailing Address - Street 2:
Mailing Address - City:WELLSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26070-2987
Mailing Address - Country:US
Mailing Address - Phone:304-639-5165
Mailing Address - Fax:
Practice Address - Street 1:302 PETTIT HEIGHTS RD
Practice Address - Street 2:
Practice Address - City:WELLSBURG
Practice Address - State:WV
Practice Address - Zip Code:26070-2987
Practice Address - Country:US
Practice Address - Phone:304-639-5165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-26
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker