Provider Demographics
NPI:1851976419
Name:BLACKWELL, DIERA (LPN)
Entity Type:Individual
Prefix:
First Name:DIERA
Middle Name:
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:377 CRYSTAL LN
Mailing Address - Street 2:
Mailing Address - City:WALTERBORO
Mailing Address - State:SC
Mailing Address - Zip Code:29488-8972
Mailing Address - Country:US
Mailing Address - Phone:843-599-3737
Mailing Address - Fax:
Practice Address - Street 1:377 CRYSTAL LN
Practice Address - Street 2:
Practice Address - City:WALTERBORO
Practice Address - State:SC
Practice Address - Zip Code:29488-8972
Practice Address - Country:US
Practice Address - Phone:843-599-3737
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-16
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC51686164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse