Healthcare Provider Details

I. General information

NPI: 1538353057
Provider Name (Legal Business Name): DAPHNE REENE BLAKLEY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2007
Last Update Date: 11/06/2024
Certification Date: 11/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 HOSPITAL DR
COLUMBIA MO
65212-0001
US

IV. Provider business mailing address

PO BOX 843966
KANSAS CITY MO
64184-3966
US

V. Phone/Fax

Practice location:
  • Phone: 573-882-8913
  • Fax: 573-884-1070
Mailing address:
  • Phone: 573-884-3300
  • Fax: 573-884-0943

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number004396
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2024033212
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: