Healthcare Provider Details

I. General information

NPI: 1679084735
Provider Name (Legal Business Name): KELLY BLANKENHAGEN PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

86TH MDG UNIT 3215 RAMSTEIN AB
APO AE
09094-3215
DE

IV. Provider business mailing address

PSC 2 BOX 9812
APO AE
09012-0099
US

V. Phone/Fax

Practice location:
  • Phone: 314-479-2609
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA10490
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA003724
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA-0705
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: