Healthcare Provider Details

I. General information

NPI: 1326306861
Provider Name (Legal Business Name): BENJAMIN MICHAEL BLANTON FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2012
Last Update Date: 05/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

946 WINFIELD DUNN PARKWAY, SUITE 107
KODAK TN
37764
US

IV. Provider business mailing address

PO BOX 32608
KNOXVILLE TN
37930-2608
US

V. Phone/Fax

Practice location:
  • Phone: 865-640-5692
  • Fax:
Mailing address:
  • Phone: 865-640-5692
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number16629
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: