Provider Demographics
NPI:1780445585
Name:BLACKWELL, MARIAH DENISE (CNA)
Entity type:Individual
Prefix:
First Name:MARIAH
Middle Name:DENISE
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:MARIAH
Other - Middle Name:DENISE
Other - Last Name:HILL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:20 MARTIN RD
Mailing Address - Street 2:
Mailing Address - City:MILAN
Mailing Address - State:TN
Mailing Address - Zip Code:38358-5524
Mailing Address - Country:US
Mailing Address - Phone:731-414-0569
Mailing Address - Fax:
Practice Address - Street 1:2865 E MAIN ST
Practice Address - Street 2:
Practice Address - City:HUMBOLDT
Practice Address - State:TN
Practice Address - Zip Code:38343-3070
Practice Address - Country:US
Practice Address - Phone:721-784-8405
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-18
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
376K00000X
TN376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide