Healthcare Provider Details

I. General information

NPI: 1356153431
Provider Name (Legal Business Name): SAVANNA BLACKWELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2025
Last Update Date: 01/24/2025
Certification Date: 01/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 ST JOSEPH ST
LOGANDALE NV
89021
US

IV. Provider business mailing address

PO BOX 1624
OVERTON NV
89040-1624
US

V. Phone/Fax

Practice location:
  • Phone: 702-397-2611
  • Fax:
Mailing address:
  • Phone: 928-234-7678
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: