Healthcare Provider Details

I. General information

NPI: 1114868395
Provider Name (Legal Business Name): MS. DORENDA BLACKMON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2026
Last Update Date: 04/02/2026
Certification Date: 04/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2080 HILLSIDE TER
AKRON OH
44305-2046
US

IV. Provider business mailing address

2080 HILLSIDE TER
AKRON OH
44305-2046
US

V. Phone/Fax

Practice location:
  • Phone: 330-701-8986
  • Fax:
Mailing address:
  • Phone: 330-701-8986
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: