Provider Demographics
NPI:1164540431
Name:BLAKELY, ANDREA M (STNA)
Entity Type:Individual
Prefix:MS
First Name:ANDREA
Middle Name:M
Last Name:BLAKELY
Suffix:
Gender:F
Credentials:STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1748 BROOKFIELD SQ N
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43229-3707
Mailing Address - Country:US
Mailing Address - Phone:614-885-6313
Mailing Address - Fax:
Practice Address - Street 1:1748 BROOKFIELD SQ N
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43229-3707
Practice Address - Country:US
Practice Address - Phone:614-885-6313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH374367241194171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2061745Medicaid