Provider Demographics
NPI:1114783818
Name:BLACKWELL, STASHA LEIGH (LVN)
Entity Type:Individual
Prefix:
First Name:STASHA
Middle Name:LEIGH
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:STASHA
Other - Middle Name:LEIGH
Other - Last Name:BRAVO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LVN
Mailing Address - Street 1:2560 N PERRIS BLVD STE N1
Mailing Address - Street 2:
Mailing Address - City:PERRIS
Mailing Address - State:CA
Mailing Address - Zip Code:92571-3251
Mailing Address - Country:US
Mailing Address - Phone:951-940-6755
Mailing Address - Fax:
Practice Address - Street 1:2560 N PERRIS BLVD STE N1
Practice Address - Street 2:
Practice Address - City:PERRIS
Practice Address - State:CA
Practice Address - Zip Code:92571-3251
Practice Address - Country:US
Practice Address - Phone:951-940-6755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-21
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA288447164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164X00000XNursing Service ProvidersLicensed Vocational NurseGroup - Multi-Specialty