Basic Information
| Provider Information | |||||||||
| NPI: | 1356508410 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLACKWELL | ||||||||
| FirstName: | LEA | ||||||||
| MiddleName: | MOREEN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7451 GLADIOLUS DR | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339085193 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2395747454 | ||||||||
| FaxNumber: | 2395749439 | ||||||||
| Practice Location | |||||||||
| Address1: | 2234 COLONIAL BLVD | ||||||||
| Address2: | MANAGED CARE DEPT. | ||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339071412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2399317342 | ||||||||
| FaxNumber: | 2399317385 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2008 | ||||||||
| LastUpdateDate: | 03/13/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208600000X | ME102649 | FL | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 463262 | 01 | FL | WELLCARE | OTHER | P00657339 | 01 | FL | RAILROAD MEDICARE | OTHER | 000373700 | 05 | FL | MEDICAID | 0172805 | 01 | FL | CIGNA | OTHER |