Provider Demographics
NPI:1750701272
Name:BLACKOWIKAK, TIMOTHY JOHN (LPN)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:JOHN
Last Name:BLACKOWIKAK
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 FOREST AVE N
Mailing Address - Street 2:
Mailing Address - City:DUNDAS
Mailing Address - State:MN
Mailing Address - Zip Code:55019-3941
Mailing Address - Country:US
Mailing Address - Phone:612-423-5639
Mailing Address - Fax:
Practice Address - Street 1:212 FOREST AVE N
Practice Address - Street 2:
Practice Address - City:DUNDAS
Practice Address - State:MN
Practice Address - Zip Code:55019-3941
Practice Address - Country:US
Practice Address - Phone:612-423-5639
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-23
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNL36999-0164W00000X, 164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No164X00000XNursing Service ProvidersLicensed Vocational Nurse