Basic Information
| Provider Information | |||||||||
| NPI: | 1043272404 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLANKENSHIP | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | CFNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 305 N 5TH ST | ||||||||
| Address2: | |||||||||
| City: | IRONTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456381578 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7405324858 | ||||||||
| FaxNumber: | 7405324859 | ||||||||
| Practice Location | |||||||||
| Address1: | 13804 STATE ROUTE 141 | ||||||||
| Address2: | |||||||||
| City: | KITTS HILL | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456458848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7406432082 | ||||||||
| FaxNumber: | 7406432126 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2006 | ||||||||
| LastUpdateDate: | 04/25/2019 | ||||||||
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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 | 363LF0000X | NP06557 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 022224 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 2274828 | 05 | OH | MEDICAID | 7101172000 | 05 | WV | MEDICAID | 78011251 | 05 | KY | MEDICAID |