Provider Demographics
NPI:1336516418
Name:BLACKMAN, TALISA
Entity Type:Individual
Prefix:
First Name:TALISA
Middle Name:
Last Name:BLACKMAN
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 1:1637 MIDDLE TN BLVD
Mailing Address - Street 2:
Mailing Address - City:MURFREESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37130-5114
Mailing Address - Country:US
Mailing Address - Phone:615-956-7375
Mailing Address - Fax:
Practice Address - Street 1:1637 MIDDLE TN BLVD
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37130-5114
Practice Address - Country:US
Practice Address - Phone:615-956-7375
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-25
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN071360332BC3200X
TN00000713601744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No1744P3200XOther Service ProvidersSpecialistProsthetics Case Management