Provider Demographics
NPI:1518182393
Name:BLACKSHEAR, TANASA MARIA (LPN)
Entity Type:Individual
Prefix:
First Name:TANASA
Middle Name:MARIA
Last Name:BLACKSHEAR
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 LAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:LINDENWOLD
Mailing Address - State:NJ
Mailing Address - Zip Code:08021-3313
Mailing Address - Country:US
Mailing Address - Phone:856-784-3958
Mailing Address - Fax:
Practice Address - Street 1:261 CONNECTICUT DR STE 5
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NJ
Practice Address - Zip Code:08016-4177
Practice Address - Country:US
Practice Address - Phone:800-950-6066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NP01143000164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse