Basic Information
| Provider Information | |||||||||
| NPI: | 1750460416 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLICKENSTAFF | ||||||||
| FirstName: | JUDITH | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4749 | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975010227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417895516 | ||||||||
| FaxNumber: | 5417895518 | ||||||||
| Practice Location | |||||||||
| Address1: | 2825 EAST BARNETT RD | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975048332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417897000 | ||||||||
| FaxNumber: | 5417747954 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2006 | ||||||||
| LastUpdateDate: | 07/09/2015 | ||||||||
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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 | 363L00000X | 079043756NI | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 079043756N1 | OR | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 034681 | 05 | OR | MEDICAID |