Provider Demographics
NPI:1407922180
Name:BLACKLEDGE, KATHLEEN
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:BLACKLEDGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:
Other - Last Name:BLACKLEDGE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RD
Mailing Address - Street 1:353 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:SEEKONK
Mailing Address - State:MA
Mailing Address - Zip Code:02771-3922
Mailing Address - Country:US
Mailing Address - Phone:508-399-8292
Mailing Address - Fax:
Practice Address - Street 1:211 PARK ST
Practice Address - Street 2:
Practice Address - City:ATTLEBORO
Practice Address - State:MA
Practice Address - Zip Code:02703-3143
Practice Address - Country:US
Practice Address - Phone:508-236-8037
Practice Address - Fax:508-236-8031
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1923133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
BLMT0823Medicare ID - Type Unspecified