Provider Demographics
NPI:1871234229
Name:BLACKNER, KAYLA MARIE
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:MARIE
Last Name:BLACKNER
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 1:1499 RIGHT FORK RD
Mailing Address - Street 2:
Mailing Address - City:MOHAWK
Mailing Address - State:WV
Mailing Address - Zip Code:24862-6400
Mailing Address - Country:US
Mailing Address - Phone:304-982-9210
Mailing Address - Fax:
Practice Address - Street 1:1499 RIGHT FORK RD
Practice Address - Street 2:
Practice Address - City:MOHAWK
Practice Address - State:WV
Practice Address - Zip Code:24862-6400
Practice Address - Country:US
Practice Address - Phone:304-982-9210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-07
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant