Provider Demographics
NPI:1598016107
Name:BLACKBURN, SHAYLA MARIE (LPN)
Entity Type:Individual
Prefix:
First Name:SHAYLA
Middle Name:MARIE
Last Name:BLACKBURN
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 1:2708 N COUNTY ROAD 1500
Mailing Address - Street 2:
Mailing Address - City:NIOTA
Mailing Address - State:IL
Mailing Address - Zip Code:62358-2112
Mailing Address - Country:US
Mailing Address - Phone:217-755-4387
Mailing Address - Fax:217-755-4387
Practice Address - Street 1:601 HIGHWAY 6 W
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52246-2209
Practice Address - Country:US
Practice Address - Phone:319-338-0581
Practice Address - Fax:319-688-3587
Is Sole Proprietor?:No
Enumeration Date:2012-09-21
Last Update Date:2012-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043067363164W00000X
IAP28748164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse