Provider Demographics
NPI:1023629409
Name:BLACKWOOD, EVADNEY VICTORIA
Entity type:Individual
Prefix:
First Name:EVADNEY
Middle Name:VICTORIA
Last Name:BLACKWOOD
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 1:626 1/2 3RD ST
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25404-4550
Mailing Address - Country:US
Mailing Address - Phone:304-919-9503
Mailing Address - Fax:
Practice Address - Street 1:626 1/2 3RD ST
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25404-4550
Practice Address - Country:US
Practice Address - Phone:304-919-9503
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-11
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant