Healthcare Provider Details

I. General information

NPI: 1831787696
Provider Name (Legal Business Name): GRACE KATHRYN BLANKENSHIP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2021
Last Update Date: 01/07/2021
Certification Date: 01/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1135 CLAYPOOL HILL MALL RD
CEDAR BLUFF VA
24609-7013
US

IV. Provider business mailing address

1135 CLAYPOOL HILL MALL RD
CEDAR BLUFF VA
24609-7013
US

V. Phone/Fax

Practice location:
  • Phone: 276-964-5748
  • Fax:
Mailing address:
  • Phone: 276-964-5748
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number0203019820
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: