Healthcare Provider Details

I. General information

NPI: 1316435118
Provider Name (Legal Business Name): TIFFANY HAZEL MENCIAS BLANKENSHIP MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2018
Last Update Date: 09/13/2021
Certification Date: 09/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1006 N H ST FL 3
ABERDEEN WA
98520-2521
US

IV. Provider business mailing address

6431 FANNIN ST
HOUSTON TX
77030-1501
US

V. Phone/Fax

Practice location:
  • Phone: 360-537-6332
  • Fax: 360-537-6322
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD61151105
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: