Provider Demographics
NPI:1750960613
Name:BLANCH, GENEVA A
Entity type:Individual
Prefix:
First Name:GENEVA
Middle Name:A
Last Name:BLANCH
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 1:29140 POINTE O WOODS PL APT 101
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-1225
Mailing Address - Country:US
Mailing Address - Phone:734-239-2670
Mailing Address - Fax:
Practice Address - Street 1:29140 POINTE O WOODS PL APT 101
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-1225
Practice Address - Country:US
Practice Address - Phone:734-239-2670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-06
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
253Z00000X, 372600000X
MI4703116916164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No253Z00000XAgenciesIn Home Supportive Care
No372600000XNursing Service Related ProvidersAdult Companion