Provider Demographics
NPI:1922447804
Name:BLACKSHIRE, FANCHON G
Entity Type:Individual
Prefix:MRS
First Name:FANCHON
Middle Name:G
Last Name:BLACKSHIRE
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 1:3620 N RANCHO DR STE 103
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89130-3153
Mailing Address - Country:US
Mailing Address - Phone:702-321-4825
Mailing Address - Fax:
Practice Address - Street 1:3620 N RANCHO DR STE 103
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89130-3153
Practice Address - Country:US
Practice Address - Phone:702-321-4825
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-24
Last Update Date:2013-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator