Provider Demographics
NPI:1902184328
Name:BLACKSHEAR, MIA LYNNAE (LPN)
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:LYNNAE
Last Name:BLACKSHEAR
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 1:1827 HOLBURN AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43207-1681
Mailing Address - Country:US
Mailing Address - Phone:614-599-9687
Mailing Address - Fax:
Practice Address - Street 1:1827 HOLBURN AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43207-1681
Practice Address - Country:US
Practice Address - Phone:614-599-9687
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-02
Last Update Date:2015-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH401195000111376K00000X
OH152393164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0061631Medicaid