Provider Demographics
NPI:1881918183
Name:BLADE, MATTHEW LEE (LPN)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:LEE
Last Name:BLADE
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 1:4646 W PIONEER RD
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55803-9347
Mailing Address - Country:US
Mailing Address - Phone:218-256-0238
Mailing Address - Fax:
Practice Address - Street 1:4646 W PIONEER RD
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55803-9347
Practice Address - Country:US
Practice Address - Phone:218-256-0238
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-16
Last Update Date:2010-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN062108-1164W00000X, 376J00000X
372500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No372500000XNursing Service Related ProvidersChore Provider
No376J00000XNursing Service Related ProvidersHomemaker