Provider Demographics
NPI:1922677855
Name:BLANCHARD UNDERWOOD, MADOLYN MARTIA (LPN)
Entity Type:Individual
Prefix:MRS
First Name:MADOLYN
Middle Name:MARTIA
Last Name:BLANCHARD UNDERWOOD
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 1:5328 E 141ST ST
Mailing Address - Street 2:
Mailing Address - City:MAPLE HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44137-3206
Mailing Address - Country:US
Mailing Address - Phone:216-414-4835
Mailing Address - Fax:
Practice Address - Street 1:15011 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:EAST CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44112-3409
Practice Address - Country:US
Practice Address - Phone:216-259-9972
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-24
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN.158848.MEDS-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse