Provider Demographics
NPI:1114575339
Name:THORNTON, LEILANI BLACKWELL (RN)
Entity Type:Individual
Prefix:
First Name:LEILANI
Middle Name:BLACKWELL
Last Name:THORNTON
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 1:141 TWIN LAKE RD
Mailing Address - Street 2:
Mailing Address - City:GAFFNEY
Mailing Address - State:SC
Mailing Address - Zip Code:29341-2526
Mailing Address - Country:US
Mailing Address - Phone:864-206-2000
Mailing Address - Fax:864-902-3628
Practice Address - Street 1:149 TWIN LAKE RD
Practice Address - Street 2:
Practice Address - City:GAFFNEY
Practice Address - State:SC
Practice Address - Zip Code:29341-2538
Practice Address - Country:US
Practice Address - Phone:864-206-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-30
Last Update Date:2019-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC68617163WS0200X
SC61617163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC68617Medicaid