Healthcare Provider Details

I. General information

NPI: 1477289080
Provider Name (Legal Business Name): KATRINA BLANKENSHIP PRSS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2022
Last Update Date: 07/26/2022
Certification Date: 07/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 LOGAN ST STE 201
WILLIAMSON WV
25661-3630
US

IV. Provider business mailing address

101 LOGAN ST STE 201
WILLIAMSON WV
25661-3630
US

V. Phone/Fax

Practice location:
  • Phone: 304-235-3570
  • Fax: 304-235-2654
Mailing address:
  • Phone: 304-235-3570
  • Fax: 304-235-2654

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number14-904
License Number StateWV
# 3
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: