Basic Information
| Provider Information | |||||||||
| NPI: | 1528145026 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLICKENSDERFER | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | CFNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 745 HASKINS RD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | BOWLING GREEN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 434021637 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193537069 | ||||||||
| FaxNumber: | 4193537076 | ||||||||
| Practice Location | |||||||||
| Address1: | 1215 RIDGEWOOD DR | ||||||||
| Address2: | SUITE B | ||||||||
| City: | BOWLING GREEN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 434022690 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193529071 | ||||||||
| FaxNumber: | 4193529073 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 06/15/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | COA.09007-NP | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 2954147 | 05 | OH | MEDICAID |