Provider Demographics
NPI:1477147346
Name:BLACKBURN, HOLLIE BETH
Entity Type:Individual
Prefix:
First Name:HOLLIE
Middle Name:BETH
Last Name:BLACKBURN
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:PO BOX 1752
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:WV
Mailing Address - Zip Code:25621-1752
Mailing Address - Country:US
Mailing Address - Phone:304-953-4475
Mailing Address - Fax:
Practice Address - Street 1:83 MITCHELL LN
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:WV
Practice Address - Zip Code:25621-9722
Practice Address - Country:US
Practice Address - Phone:304-953-4475
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-22
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker