Basic Information
| Provider Information | |||||||||
| NPI: | 1619504420 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLANKENSHIP | ||||||||
| FirstName: | KYLE | ||||||||
| MiddleName: | STEVEN | ||||||||
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| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1101 DOWNS BLVD APT B107 | ||||||||
| Address2: | |||||||||
| City: | FRANKLIN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370643853 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3172095459 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 516 E NIZHONI BLVD | ||||||||
| Address2: | |||||||||
| City: | GALLUP | ||||||||
| State: | NM | ||||||||
| PostalCode: | 873015748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057221000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2020 | ||||||||
| LastUpdateDate: | 03/24/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 213829 | TN | Y | Nursing Service Providers | Registered Nurse |
No ID Information.