Provider Demographics
NPI:1215540430
Name:BLACKMON, SHERONDA LANETTA (LPN)
Entity Type:Individual
Prefix:
First Name:SHERONDA
Middle Name:LANETTA
Last Name:BLACKMON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13929 HARPER AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48213-3672
Mailing Address - Country:US
Mailing Address - Phone:313-371-0055
Mailing Address - Fax:313-469-7072
Practice Address - Street 1:13929 HARPER AVE.
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48213
Practice Address - Country:US
Practice Address - Phone:313-371-0055
Practice Address - Fax:313-469-7072
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-27
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703080391164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse