Provider Demographics
NPI:1841791431
Name:BLODGETT, STACIE MAGDELENA
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:MAGDELENA
Last Name:BLODGETT
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 1:606 EDDY ST
Mailing Address - Street 2:
Mailing Address - City:QUANAH
Mailing Address - State:TX
Mailing Address - Zip Code:79252-4542
Mailing Address - Country:US
Mailing Address - Phone:940-642-4150
Mailing Address - Fax:
Practice Address - Street 1:606 EDDY ST
Practice Address - Street 2:
Practice Address - City:QUANAH
Practice Address - State:TX
Practice Address - Zip Code:79252-4542
Practice Address - Country:US
Practice Address - Phone:940-642-4150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-28
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX184592164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX184592OtherLVN LICENSE