Basic Information
| Provider Information | |||||||||
| NPI: | 1902198708 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLY | ||||||||
| FirstName: | KC | ||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | LNM | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1260 | ||||||||
| Address2: | |||||||||
| City: | DAVIS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956171260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5307533498 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2051 JOHN JONES RD | ||||||||
| Address2: | |||||||||
| City: | DAVIS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956169701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5307533498 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2011 | ||||||||
| LastUpdateDate: | 10/28/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 176B00000X | R193861 | MD | N | Other Service Providers | Midwife | 176B00000X | 1922 | CA | N | Other Service Providers | Midwife | 367A00000X | 000352 | CT | N | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife | 367A00000X | 11347841-4405 | UT | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 009003526 | 05 | CT | MEDICAID |