Provider Demographics
NPI:1861168056
Name:BLAKLEY, MACEY SHANAE
Entity type:Individual
Prefix:
First Name:MACEY
Middle Name:SHANAE
Last Name:BLAKLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MACEY
Other - Middle Name:SHANAE
Other - Last Name:PIERCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3000 S 9TH AVE TRLR 91
Mailing Address - Street 2:
Mailing Address - City:PURCELL
Mailing Address - State:OK
Mailing Address - Zip Code:73080-8441
Mailing Address - Country:US
Mailing Address - Phone:580-380-5652
Mailing Address - Fax:
Practice Address - Street 1:3000 S 9TH AVE TRLR 91
Practice Address - Street 2:
Practice Address - City:PURCELL
Practice Address - State:OK
Practice Address - Zip Code:73080-8441
Practice Address - Country:US
Practice Address - Phone:580-380-5652
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-18
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program