| Doctor Name: | MARYAM BLACKEAGLE |
| NPI Number: | 1104285881 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | |
| License Number: | 4703085481 |
| Business Practice Address: | 8445 Norborne Ave Dearborn Heights, MI - 481271125 |
| Business Phone Number: | 7347273010 |
| Business Fax Number: | |
| Mailing Address: | 8445 Norborne Ave, DEARBORN HEIGHTS |
| State: | MI |
| Postal Code: | 481271125 |
| Phone Number: | 7347273010 |
| Fax Number: | |
| NPI Enumeration Date: | 02/23/2016 |
| NPI Last Update Date: | 02/23/2016 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 164W00000X |
| License Number: | 4703085481 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MI |
| Taxonomy Type: | Nursing Service Providers |
| Taxonomy Classification: | Licensed Practical Nurse |
| Taxonomy Specialization: | |
| Taxonomy Definition: | An individual with post-high school vocational training and practical experience in the provision of nursing care at a level less than that required for certification as a Registered Nurse. Requirements for education, experience, licensure, and job responsibilities vary among the states. |