Provider Demographics
NPI:1437659125
Name:YOUNGBLOOD, LACRESHA DANYELL
Entity Type:Individual
Prefix:
First Name:LACRESHA
Middle Name:DANYELL
Last Name:YOUNGBLOOD
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 1:2801 BILL OWENS PKWY APT 203
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605-2169
Mailing Address - Country:US
Mailing Address - Phone:903-490-6430
Mailing Address - Fax:
Practice Address - Street 1:755 S BECKHAM AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-1903
Practice Address - Country:US
Practice Address - Phone:903-534-4684
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-19
Last Update Date:2018-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARL043813164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse