Provider Demographics
NPI:1518296052
Name:BLAKEMAN, FARON
Entity Type:Individual
Prefix:MR
First Name:FARON
Middle Name:
Last Name:BLAKEMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:728 E BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:CAMPBELLSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42718-1504
Mailing Address - Country:US
Mailing Address - Phone:270-465-4047
Mailing Address - Fax:270-469-9747
Practice Address - Street 1:728 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:CAMPBELLSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42718-1504
Practice Address - Country:US
Practice Address - Phone:270-465-4047
Practice Address - Fax:270-469-9747
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-11
Last Update Date:2009-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY494237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY203810955OtherTAX ID