Basic Information
Provider Information | |||||||||
NPI: | 1972027373 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BLANDFORD | ||||||||
FirstName: | KRISTEN | ||||||||
MiddleName: | KENNEDY | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3814 BUNCOMBE DR | ||||||||
Address2: |   | ||||||||
City: | GREENSBORO | ||||||||
State: | NC | ||||||||
PostalCode: | 274077326 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3368600981 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 4002 ELTON WAY STE 104 | ||||||||
Address2: |   | ||||||||
City: | GREENSBORO | ||||||||
State: | NC | ||||||||
PostalCode: | 274068973 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3368600981 | ||||||||
FaxNumber: | 3369074714 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/28/2017 | ||||||||
LastUpdateDate: | 03/05/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/05/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 0024175208 | VA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 1257845 | 01 | VA | VA BOARD OF NURSING | OTHER | 5013634 | 01 | NC | NC BOARD OF NURSING | OTHER |