Healthcare Provider Details

I. General information

NPI: 1467288472
Provider Name (Legal Business Name): MRS. ROBIN VANESSA BLAISDELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2024
Last Update Date: 09/09/2024
Certification Date: 09/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

214 W CENTER ST
HERNANDO MS
38632-2242
US

IV. Provider business mailing address

6695 WHITE HAWK LN
OLIVE BRANCH MS
38654-7382
US

V. Phone/Fax

Practice location:
  • Phone: 662-782-6770
  • Fax:
Mailing address:
  • Phone: 662-782-6770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number969
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: