Provider Demographics
NPI:1518572767
Name:DIAMOND, BLAKK
Entity Type:Individual
Prefix:
First Name:BLAKK
Middle Name:
Last Name:DIAMOND
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 1:405 PHILIP BLVD APT 1305
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-8749
Mailing Address - Country:US
Mailing Address - Phone:706-403-7257
Mailing Address - Fax:
Practice Address - Street 1:405 PHILIP BLVD APT 1305
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-8749
Practice Address - Country:US
Practice Address - Phone:706-403-7257
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-14
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT011268172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Single Specialty