Basic Information
Provider Information | |||||||||
NPI: | 1134448715 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BLENCH | ||||||||
FirstName: | ANNE | ||||||||
MiddleName: | KAGEY | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-AA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | KAGEY | ||||||||
OtherFirstName: | ANNE | ||||||||
OtherMiddleName: | DIAMOND | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA-AA | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 551420 | ||||||||
Address2: |   | ||||||||
City: | FORT LAUDERDALE | ||||||||
State: | FL | ||||||||
PostalCode: | 333551420 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8002433839 | ||||||||
FaxNumber: | 8558514405 | ||||||||
Practice Location | |||||||||
Address1: | 1968 PEACHTREE RD., NW | ||||||||
Address2: |   | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 303091281 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4043511745 | ||||||||
FaxNumber: | 4043517121 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/22/2010 | ||||||||
LastUpdateDate: | 02/03/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367H00000X |   |   | N |   | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |   | 367H00000X | 005911 | GA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 735072500A | 05 | GA |   | MEDICAID | 003100366B | 05 | GA |   | MEDICAID |