Provider Demographics
NPI:1114236429
Name:BLACKFORD, ANNA L
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:L
Last Name:BLACKFORD
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:PO BOX 573
Mailing Address - Street 2:
Mailing Address - City:PONDERAY
Mailing Address - State:ID
Mailing Address - Zip Code:83852-0573
Mailing Address - Country:US
Mailing Address - Phone:208-290-1079
Mailing Address - Fax:
Practice Address - Street 1:455 39 G RD
Practice Address - Street 2:
Practice Address - City:SAGLE
Practice Address - State:ID
Practice Address - Zip Code:83860-8960
Practice Address - Country:US
Practice Address - Phone:208-290-1079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-04
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDQK307464B347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle