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NPI Code Detail

MEDICARE: LADONNA RENEE BLACKBEAR

MEDICARE: LADONNA RENEE BLACKBEAR
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
1175T00000XPeer SpecialistOK

General Provider Information

NPI Number : 1104625201
Entity Type Code : Individual
Provider Name (Legal Business Name) : LADONNA RENEE BLACKBEAR
Provider Business Mailing Address
First Line : 113 W KEETOOWAH ST
Second Line :
City : TAHLEQUAH
State : OK
Zip : 74464-3819
Country : US
Telephone Number : 918-931-3700
Fax Number :
Provider Business Practice Location Address
First Line : 113 W KEETOOWAH ST
Second Line :
City : TAHLEQUAH
State : OK
Zip : 74464-3819
Country : US
Telephone Number : 918-931-3700
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/11/2025
Last Update Date : 03/11/2025

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Directions to “ LADONNA RENEE BLACKBEAR ” Practice Location

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