Provider Demographics
NPI:1831805894
Name:BLACKMON-LACY, TOSHA (LVN)
Entity type:Individual
Prefix:
First Name:TOSHA
Middle Name:
Last Name:BLACKMON-LACY
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 1:505 N GREEN ST STE 3
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75601-6408
Mailing Address - Country:US
Mailing Address - Phone:903-235-1441
Mailing Address - Fax:
Practice Address - Street 1:505 N GREEN ST STE 3
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-6408
Practice Address - Country:US
Practice Address - Phone:903-235-1441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-24
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX300228164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse