Basic Information
| Provider Information | |||||||||
| NPI: | 1982717484 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLANKENSHIP | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | DAWN | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | MEDICAL CENTER BLVD | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271570001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367162255 | ||||||||
| FaxNumber: | 3367163202 | ||||||||
| Practice Location | |||||||||
| Address1: | 1249 15TH ST | ||||||||
| Address2: | SUITE 4093 | ||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257013662 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046918714 | ||||||||
| FaxNumber: | 3046918591 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2006 | ||||||||
| LastUpdateDate: | 05/30/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 1973 | WV | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | 103658 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | P00247717 | 01 | RAILROAD MEDICARE | OTHER | 0251PA | 05 | SC | MEDICAID |