Provider Demographics
NPI:1295299667
Name:BLACKFORD, HEATHER RAELYN (RN)
Entity type:Individual
Prefix:MS
First Name:HEATHER
Middle Name:RAELYN
Last Name:BLACKFORD
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:RAELYN
Other - Last Name:HANSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:41847 JOHNSTON AVE
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92544-7535
Mailing Address - Country:US
Mailing Address - Phone:951-445-1550
Mailing Address - Fax:
Practice Address - Street 1:41847 JOHNSTON AVE
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92544-7535
Practice Address - Country:US
Practice Address - Phone:951-445-1550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-30
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95037248163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse