Provider Demographics
NPI:1891399705
Name:BLEVINS, LANISHA ANTOINETTE (NURSE)
Entity Type:Individual
Prefix:MISS
First Name:LANISHA
Middle Name:ANTOINETTE
Last Name:BLEVINS
Suffix:
Gender:F
Credentials:NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1574 W RIVER PARK DR
Mailing Address - Street 2:
Mailing Address - City:INKSTER
Mailing Address - State:MI
Mailing Address - Zip Code:48141-1836
Mailing Address - Country:US
Mailing Address - Phone:313-758-8362
Mailing Address - Fax:
Practice Address - Street 1:1574 W RIVER PARK DR
Practice Address - Street 2:
Practice Address - City:INKSTER
Practice Address - State:MI
Practice Address - Zip Code:48141-1836
Practice Address - Country:US
Practice Address - Phone:313-758-8362
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-23
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1492119164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse