Provider Demographics
NPI:1730475682
Name:HEADLEY BLACKERBY, JOHNNA LEIGH (OD)
Entity Type:Individual
Prefix:MS
First Name:JOHNNA
Middle Name:LEIGH
Last Name:HEADLEY BLACKERBY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1239 HIGHWAY 46
Mailing Address - Street 2:
Mailing Address - City:SHELBY
Mailing Address - State:AL
Mailing Address - Zip Code:35143-5225
Mailing Address - Country:US
Mailing Address - Phone:205-337-8715
Mailing Address - Fax:
Practice Address - Street 1:22767 HIGHWAY 25
Practice Address - Street 2:
Practice Address - City:COLUMBIANA
Practice Address - State:AL
Practice Address - Zip Code:35051-3529
Practice Address - Country:US
Practice Address - Phone:205-669-4131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-20
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS-C58-TA-896152W00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist