Provider Demographics
NPI:1710315015
Name:BLACKWELL, LUCSHUNDA
Entity Type:Individual
Prefix:
First Name:LUCSHUNDA
Middle Name:
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 1:1149 BETHANY AVE
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44305-2612
Mailing Address - Country:US
Mailing Address - Phone:330-510-7847
Mailing Address - Fax:
Practice Address - Street 1:1149 BETHANY AVE
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44305-2612
Practice Address - Country:US
Practice Address - Phone:330-510-7847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-23
Last Update Date:2013-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker