Provider Demographics
NPI:1942759253
Name:BLACKMON, CARLA (LVN)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:
Last Name:BLACKMON
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 233335
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95823-0438
Mailing Address - Country:US
Mailing Address - Phone:916-267-1065
Mailing Address - Fax:
Practice Address - Street 1:900 FULTON AVE STE 205
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-4517
Practice Address - Country:US
Practice Address - Phone:916-484-3570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-27
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN190633164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse