Provider Demographics
NPI:1518621424
Name:BLAKLEY, NATAUSHA
Entity Type:Individual
Prefix:
First Name:NATAUSHA
Middle Name:
Last Name:BLAKLEY
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 1:501 W BUTLER RD # A2
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-4879
Mailing Address - Country:US
Mailing Address - Phone:864-787-7891
Mailing Address - Fax:
Practice Address - Street 1:501 W BUTLER RD STE A2
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-4879
Practice Address - Country:US
Practice Address - Phone:864-787-7891
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-26
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCIHCP-1616253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNAMedicaid