Provider Demographics
NPI:1376786343
Name:BLAECKBOURN-CRAHEN, MARIAH JENTIEL
Entity Type:Individual
Prefix:MRS
First Name:MARIAH
Middle Name:JENTIEL
Last Name:BLAECKBOURN-CRAHEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARIAH
Other - Middle Name:JENTIEL
Other - Last Name:BLAECKBOURN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSN-CNP
Mailing Address - Street 1:600 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44906-2633
Mailing Address - Country:US
Mailing Address - Phone:419-522-6191
Mailing Address - Fax:
Practice Address - Street 1:600 W 3RD ST
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44906-2633
Practice Address - Country:US
Practice Address - Phone:419-522-6191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP 10470363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily