Provider Demographics
NPI:1942823638
Name:BLACKFORD, HEIDI MERRIE (RN)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:MERRIE
Last Name:BLACKFORD
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:144 PLEASANT AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:12095-1202
Mailing Address - Country:US
Mailing Address - Phone:518-706-8948
Mailing Address - Fax:
Practice Address - Street 1:234 LINCOLN ST
Practice Address - Street 2:
Practice Address - City:GLOVERSVILLE
Practice Address - State:NY
Practice Address - Zip Code:12078-1935
Practice Address - Country:US
Practice Address - Phone:518-706-8948
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-28
Last Update Date:2020-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY618110163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse