Provider Demographics
NPI:1871061572
Name:BLACKBURN, SHARONE MARIE
Entity type:Individual
Prefix:
First Name:SHARONE
Middle Name:MARIE
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 GOFFS FALLS RD
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03103-6109
Mailing Address - Country:US
Mailing Address - Phone:800-995-2673
Mailing Address - Fax:
Practice Address - Street 1:273 E BEVERLY BLVD
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-3775
Practice Address - Country:US
Practice Address - Phone:323-724-5100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-12
Last Update Date:2018-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA694107164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse