Provider Demographics
NPI:1922573450
Name:BLACKMON, JOYCE (LPN (LICENSED PRACTI)
Entity Type:Individual
Prefix:
First Name:JOYCE
Middle Name:
Last Name:BLACKMON
Suffix:
Gender:F
Credentials:LPN (LICENSED PRACTI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 NORTH ASHLAND AVENUE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607
Mailing Address - Country:US
Mailing Address - Phone:312-850-9411
Mailing Address - Fax:312-850-3288
Practice Address - Street 1:140 NORTH ASHLAND AVENUE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607
Practice Address - Country:US
Practice Address - Phone:312-850-9411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-11
Last Update Date:2018-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043.070139164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse