Basic Information
| Provider Information | |||||||||
| NPI: | 1871898866 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RICHARDSON | ||||||||
| FirstName: | BLAIR | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | C.R.N.A. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BRUCE | ||||||||
| OtherFirstName: | BLAIR | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CRNA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 639 NORTH MULBERRY STREET | ||||||||
| Address2: | |||||||||
| City: | ELIZABETHTOWN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427011931 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707374600 | ||||||||
| FaxNumber: | 2707371722 | ||||||||
| Practice Location | |||||||||
| Address1: | 639 NORTH MULBERRY STREET | ||||||||
| Address2: | |||||||||
| City: | ELIZABETHTOWN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427011931 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707374600 | ||||||||
| FaxNumber: | 2707371722 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/21/2011 | ||||||||
| LastUpdateDate: | 03/12/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 085894 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 7100154900 | 05 | KY | MEDICAID |