Provider Demographics
NPI:1407499288
Name:BLAKELY, CHERYL MARIE (LPN)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:MARIE
Last Name:BLAKELY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8472 STATE ROUTE 20
Mailing Address - Street 2:
Mailing Address - City:WATERVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13480-2416
Mailing Address - Country:US
Mailing Address - Phone:315-749-8822
Mailing Address - Fax:
Practice Address - Street 1:8472 STATE ROUTE 20
Practice Address - Street 2:
Practice Address - City:WATERVILLE
Practice Address - State:NY
Practice Address - Zip Code:13480-2416
Practice Address - Country:US
Practice Address - Phone:315-749-8822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-23
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY272711-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse