Provider Demographics
NPI:1376731299
Name:BLAKENSHIP, DE ETTA LYNN
Entity Type:Individual
Prefix:
First Name:DE ETTA
Middle Name:LYNN
Last Name:BLAKENSHIP
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 1:1316 SOMERVILLE RD SE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35601-4305
Mailing Address - Country:US
Mailing Address - Phone:256-355-6105
Mailing Address - Fax:
Practice Address - Street 1:1315 13TH AVE SE
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:AL
Practice Address - Zip Code:35601-4308
Practice Address - Country:US
Practice Address - Phone:256-355-6105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-04
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASE MANAGER171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator