Basic Information
| Provider Information | |||||||||
| NPI: | 1598325136 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLANTON | ||||||||
| FirstName: | KELECHI | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 542922 | ||||||||
| Address2: | |||||||||
| City: | GRAND PRAIRIE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750542922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6122359988 | ||||||||
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| Practice Location | |||||||||
| Address1: | 601 S CLAY ST STE 105 | ||||||||
| Address2: | |||||||||
| City: | ENNIS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 751195771 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9728756600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2019 | ||||||||
| LastUpdateDate: | 06/17/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | AP141146 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363LG0600X | AP141146 | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
No ID Information.