Provider Demographics
NPI:1437940335
Name:BLACKA, SHIRLEY MARIE
Entity type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:MARIE
Last Name:BLACKA
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 1:51 JONES ST APT 405
Mailing Address - Street 2:
Mailing Address - City:PIEDMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26750-1017
Mailing Address - Country:US
Mailing Address - Phone:681-589-1175
Mailing Address - Fax:
Practice Address - Street 1:51 JONES ST APT 405
Practice Address - Street 2:
Practice Address - City:PIEDMONT
Practice Address - State:WV
Practice Address - Zip Code:26750-1017
Practice Address - Country:US
Practice Address - Phone:681-589-1175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-13
Last Update Date:2025-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant