Provider Demographics
NPI:1356643464
Name:BLACKMAN, ANGELA L (CNA)
Entity Type:Individual
Prefix:MS
First Name:ANGELA
Middle Name:L
Last Name:BLACKMAN
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:MISS
Other - First Name:ANGELA
Other - Middle Name:L
Other - Last Name:FARRELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNA
Mailing Address - Street 1:4653 LEE ROAD 379
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:AL
Mailing Address - Zip Code:36874-3607
Mailing Address - Country:US
Mailing Address - Phone:334-291-7629
Mailing Address - Fax:334-297-8711
Practice Address - Street 1:4653 LEE ROAD 379
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:AL
Practice Address - Zip Code:36874-3607
Practice Address - Country:US
Practice Address - Phone:334-291-7629
Practice Address - Fax:334-297-8711
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-22
Last Update Date:2010-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACN0000056958376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide