Provider Demographics
NPI:1689280117
Name:BLACKWELL, PRINCESS NAILAH
Entity Type:Individual
Prefix:
First Name:PRINCESS
Middle Name:NAILAH
Last Name:BLACKWELL
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 1:2844 FREDRICK DOUGLAS BLVD
Mailing Address - Street 2:APT# 5C
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10039
Mailing Address - Country:US
Mailing Address - Phone:347-863-3654
Mailing Address - Fax:
Practice Address - Street 1:2844 FREDRICK DOUGLAS BLVD
Practice Address - Street 2:APT# 5C
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10039
Practice Address - Country:US
Practice Address - Phone:347-863-3654
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-21
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY338655164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse