MEDICARE: DONNA BLACKBURN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172V00000X	Community Health Worker

General Provider Information

NPI Number	:	1043804354
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DONNA BLACKBURN

Provider Business Mailing Address
First Line	:	302 PETTIT HEIGHTS RD
Second Line	:
City	:	WELLSBURG
State	:	WV
Zip	:	26070-2987
Country	:	US
Telephone Number	:	304-639-5165
Fax Number	:

Provider Business Practice Location Address
First Line	:	302 PETTIT HEIGHTS RD
Second Line	:
City	:	WELLSBURG
State	:	WV
Zip	:	26070-2987
Country	:	US
Telephone Number	:	304-639-5165
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/26/2021
Last Update Date	:	02/26/2021

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Directions to “ DONNA BLACKBURN ” Practice Location

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