Provider Demographics
NPI:1457545444
Name:BLADES, MARVALENE AMANDA (LVN)
Entity Type:Individual
Prefix:MS
First Name:MARVALENE
Middle Name:AMANDA
Last Name:BLADES
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 1:1427 W JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90007-3419
Mailing Address - Country:US
Mailing Address - Phone:323-730-8063
Mailing Address - Fax:323-730-8063
Practice Address - Street 1:1427 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90007-3419
Practice Address - Country:US
Practice Address - Phone:323-730-8063
Practice Address - Fax:323-730-8063
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-01
Last Update Date:2007-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA132322164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEPSO014480Medicaid
CARVN002830Medicaid