Provider Demographics
NPI:1487197232
Name:BLACKMON, CODY
Entity type:Individual
Prefix:MRS
First Name:CODY
Middle Name:
Last Name:BLACKMON
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 1:538 HIWASSEE DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:TN
Mailing Address - Zip Code:37322-6033
Mailing Address - Country:US
Mailing Address - Phone:405-406-7977
Mailing Address - Fax:
Practice Address - Street 1:9901 N MAY AVE STE 110
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-2734
Practice Address - Country:US
Practice Address - Phone:405-849-5624
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-28
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN272468163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant