Basic Information
| Provider Information | |||||||||
| NPI: | 1518553460 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLANTON | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | ANGEL | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RN | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1015 W WASHBOURNE ST | ||||||||
| Address2: | |||||||||
| City: | JAY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 743464205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9183085513 | ||||||||
| FaxNumber: | 9187864435 | ||||||||
| Practice Location | |||||||||
| Address1: | 1015 W WASHBOURNE ST | ||||||||
| Address2: | |||||||||
| City: | JAY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 743464205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9183085513 | ||||||||
| FaxNumber: | 9187864435 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2020 | ||||||||
| LastUpdateDate: | 12/15/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | R0137181 | OK | Y | Nursing Service Providers | Registered Nurse |
No ID Information.