Provider Demographics
NPI:1639414923
Name:BLACKWELL, ANN (CEDRD, RD, LD)
Entity Type:Individual
Prefix:MRS
First Name:ANN
Middle Name:
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:CEDRD, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:226 WHITEOAK AVE
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:MS
Mailing Address - Zip Code:39153-6082
Mailing Address - Country:US
Mailing Address - Phone:601-782-9919
Mailing Address - Fax:601-782-9920
Practice Address - Street 1:226 WHITEOAK AVE
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:MS
Practice Address - Zip Code:39153-6082
Practice Address - Country:US
Practice Address - Phone:601-782-9919
Practice Address - Fax:601-782-9920
Is Sole Proprietor?:No
Enumeration Date:2012-11-28
Last Update Date:2012-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSD0705133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered