Provider Demographics
NPI:1518179530
Name:BLACKWELL, MARYANN (RN)
Entity Type:Individual
Prefix:
First Name:MARYANN
Middle Name:
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5674 STONERIDGE DR STE 116
Mailing Address - Street 2:
Mailing Address - City:PLEASANTON
Mailing Address - State:CA
Mailing Address - Zip Code:94588-8536
Mailing Address - Country:US
Mailing Address - Phone:925-520-0005
Mailing Address - Fax:925-520-0010
Practice Address - Street 1:411 30TH ST STE 314
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3303
Practice Address - Country:US
Practice Address - Phone:510-273-4200
Practice Address - Fax:510-273-8340
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA635931163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health