Healthcare Provider Details

I. General information

NPI: 1174634562
Provider Name (Legal Business Name): KRISTIN BLANKENSHIP PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 11/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

747 N RUTLEDGE ST 3RD FLOOR
SPRINGFIELD IL
62702-6700
US

IV. Provider business mailing address

PO BOX 19653
SPRINGFIELD IL
62794-9653
US

V. Phone/Fax

Practice location:
  • Phone: 217-545-8000
  • Fax: 217-545-2588
Mailing address:
  • Phone: 217-545-8000
  • Fax: 217-545-2588

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number085004979
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: