Provider Demographics
NPI:1407600695
Name:BLACKMAN, TONYA SUE (RN)
Entity Type:Individual
Prefix:
First Name:TONYA
Middle Name:SUE
Last Name:BLACKMAN
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 1:2401 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-1188
Mailing Address - Country:US
Mailing Address - Phone:618-997-7676
Mailing Address - Fax:
Practice Address - Street 1:3675 BATTLEFORD RD
Practice Address - Street 2:
Practice Address - City:STONEFORT
Practice Address - State:IL
Practice Address - Zip Code:62987-1342
Practice Address - Country:US
Practice Address - Phone:618-964-5378
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-15
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.322202163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse