Provider Demographics
NPI:1033949243
Name:BLACKMON, TAIYONNA MARSHEA LYNNESE (LPN)
Entity type:Individual
Prefix:
First Name:TAIYONNA
Middle Name:MARSHEA LYNNESE
Last Name:BLACKMON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4577 CARTER AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63115-2516
Mailing Address - Country:US
Mailing Address - Phone:314-410-9117
Mailing Address - Fax:
Practice Address - Street 1:4577 CARTER AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63115-2516
Practice Address - Country:US
Practice Address - Phone:314-410-9117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-02
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020033205164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse