1356358477 NPI number — MS. MARY LOUISE BLANKENSHIP RN, FNP, PMHNP-BC

Table of content: MS. MARY LOUISE BLANKENSHIP RN, FNP, PMHNP-BC (NPI 1356358477)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356358477 NPI number — MS. MARY LOUISE BLANKENSHIP RN, FNP, PMHNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLANKENSHIP
Provider First Name:
MARY
Provider Middle Name:
LOUISE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
RN, FNP, PMHNP-BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356358477
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/12/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1907 NW 6TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HERMISTON
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97838-1148
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-825-2575
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3188 SOUTHERN BLVD SE STE B1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIO RANCHO
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87124-1989
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-200-9158
Provider Business Practice Location Address Fax Number:
505-200-9497
Provider Enumeration Date:
08/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP2300X , with the licence number:  0375722 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0808X , with the licence number: 2023150476 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3017279-01 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 77056396 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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