Provider Demographics
NPI:1710482542
Name:BLOCKMON, LANISHA
Entity Type:Individual
Prefix:MS
First Name:LANISHA
Middle Name:
Last Name:BLOCKMON
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 1:8214 S EVANS AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60619-5306
Mailing Address - Country:US
Mailing Address - Phone:773-853-6694
Mailing Address - Fax:
Practice Address - Street 1:8214 S EVANS AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60619-5306
Practice Address - Country:US
Practice Address - Phone:773-853-6694
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-25
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor