Provider Demographics
NPI:1407607476
Name:BLACKWELL, SANDRA LEE
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:LEE
Last Name:BLACKWELL
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 1:4728 WOLF RUN AVE SE
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49548-7570
Mailing Address - Country:US
Mailing Address - Phone:616-734-3204
Mailing Address - Fax:
Practice Address - Street 1:4728 WOLF RUN AVE SE
Practice Address - Street 2:
Practice Address - City:KENTWOOD
Practice Address - State:MI
Practice Address - Zip Code:49548-7570
Practice Address - Country:US
Practice Address - Phone:616-734-3204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-28
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI372500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372500000XNursing Service Related ProvidersChore Provider