Healthcare Provider Details

I. General information

NPI: 1649731514
Provider Name (Legal Business Name): EUSHEAKIA BLAKENEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: EUSHEAKIA WITHERSPOON

II. Dates (important events)

Enumeration Date: 03/25/2019
Last Update Date: 03/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1190 W ROOSEVELT BLVD
MONROE NC
28110-2818
US

IV. Provider business mailing address

284 EXECUTIVE PARK DR STE 100
CONCORD NC
28025-1833
US

V. Phone/Fax

Practice location:
  • Phone: 704-296-6200
  • Fax: 704-296-4669
Mailing address:
  • Phone: 704-939-1100
  • Fax: 704-939-1173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License Number90565
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: