Provider Demographics
NPI:1720583263
Name:BLAKELEY, PAMELA KATHLEEN
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:KATHLEEN
Last Name:BLAKELEY
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:PO BOX 901
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:TX
Mailing Address - Zip Code:75657-0901
Mailing Address - Country:US
Mailing Address - Phone:903-665-6131
Mailing Address - Fax:903-665-7244
Practice Address - Street 1:120 N WALNUT ST
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:TX
Practice Address - Zip Code:75657-1934
Practice Address - Country:US
Practice Address - Phone:903-665-6131
Practice Address - Fax:903-665-7244
Is Sole Proprietor?:No
Enumeration Date:2018-03-27
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant