Provider Demographics
NPI:1508636671
Name:BLACKINTON, ANGELA (LMT)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:BLACKINTON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3041 N CONSTANCE DR APT A
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86314-8912
Mailing Address - Country:US
Mailing Address - Phone:928-233-0025
Mailing Address - Fax:
Practice Address - Street 1:8363 E FLORENTINE RD STE C
Practice Address - Street 2:
Practice Address - City:PRESCOTT VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86314-4972
Practice Address - Country:US
Practice Address - Phone:928-233-0025
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-08
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-25646225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist