Provider Demographics
NPI:1336678317
Name:BLAKELY, LISA DOVE (RN)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:DOVE
Last Name:BLAKELY
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 1:1659 WOODBRIDGE LN NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30329-3536
Mailing Address - Country:US
Mailing Address - Phone:678-548-1416
Mailing Address - Fax:
Practice Address - Street 1:1659 WOODBRIDGE LN NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-3536
Practice Address - Country:US
Practice Address - Phone:678-548-1416
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-05
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN127654163WA2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA2000XNursing Service ProvidersRegistered NurseAdministrator