Healthcare Provider Details

I. General information

NPI: 1356617252
Provider Name (Legal Business Name): KAREN BLAKELEY DVM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2012
Last Update Date: 03/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

722 W JACKSON ST
MACOMB IL
61455-2012
US

IV. Provider business mailing address

722 W JACKSON ST
MACOMB IL
61455-2012
US

V. Phone/Fax

Practice location:
  • Phone: 309-833-2365
  • Fax:
Mailing address:
  • Phone: 309-833-2365
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174M00000X
TaxonomyVeterinarian
License Number090-007699
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: