Healthcare Provider Details

I. General information

NPI: 1689420424
Provider Name (Legal Business Name): LEASA LASAE BLACKMON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2024
Last Update Date: 04/24/2024
Certification Date: 04/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 MITCHELL BRIDGE RD
ATHENS GA
30606-2043
US

IV. Provider business mailing address

PO BOX 490182
LAWRENCEVILLE GA
30049-0004
US

V. Phone/Fax

Practice location:
  • Phone: 770-910-9196
  • Fax: 678-682-8747
Mailing address:
  • Phone: 470-232-5119
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number221219
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: