Provider Demographics
NPI:1558934364
Name:BLACKWELL-CLARY, DESTINEE D (LPN)
Entity Type:Individual
Prefix:
First Name:DESTINEE
Middle Name:D
Last Name:BLACKWELL-CLARY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:DESTINEE
Other - Middle Name:D
Other - Last Name:BLACKWELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 188
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:OH
Mailing Address - Zip Code:45601-0188
Mailing Address - Country:US
Mailing Address - Phone:740-773-4366
Mailing Address - Fax:740-773-4750
Practice Address - Street 1:8978 UNITED LN STE 102
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:OH
Practice Address - Zip Code:45701-3668
Practice Address - Country:US
Practice Address - Phone:740-274-4246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-20
Last Update Date:2022-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN.177387.MEDS-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse