MEDICARE: SHANNON BLANKENBECKLER AGNP-C, PMHNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2200X	Adult Health Nurse Practitioner	BLAN-GIKLC9	NC
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	5007563	NC

General Provider Information

NPI Number	:	1508257221
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNON BLANKENBECKLER AGNP-C, PMHNP-BC

Provider Business Mailing Address
First Line	:	611 LAVEEN WAY
Second Line	:
City	:	WILMINGTON
State	:	NC
Zip	:	28412-2697
Country	:	US
Telephone Number	:	910-470-8496
Fax Number	:

Provider Business Practice Location Address
First Line	:	2909 MARKET ST
Second Line	:
City	:	WILMINGTON
State	:	NC
Zip	:	28403-1221
Country	:	US
Telephone Number	:	910-795-2118
Fax Number	:	910-795-2318

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/17/2015
Last Update Date	:	07/24/2022

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