Provider Demographics
NPI:1255077947
Name:BLACKSHEAR, QUINTANA
Entity type:Individual
Prefix:
First Name:QUINTANA
Middle Name:
Last Name:BLACKSHEAR
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 1:1052 MERCER ST
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44502-1530
Mailing Address - Country:US
Mailing Address - Phone:330-974-2813
Mailing Address - Fax:
Practice Address - Street 1:1052 MERCER ST
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44502-1530
Practice Address - Country:US
Practice Address - Phone:330-974-2813
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-06
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0484669Medicaid