Healthcare Provider Details

I. General information

NPI: 1053093062
Provider Name (Legal Business Name): ALYZEA BLANKENSHIP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2023
Last Update Date: 08/01/2023
Certification Date: 08/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1048 ASHLEY ST STE 101
BOWLING GREEN KY
42103-2449
US

IV. Provider business mailing address

1321 MURFREESBORO PIKE STE 410
NASHVILLE TN
37217-2665
US

V. Phone/Fax

Practice location:
  • Phone: 270-843-5300
  • Fax: 615-815-1946
Mailing address:
  • Phone: 615-247-5487
  • Fax: 615-815-1946

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-23-284969
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: