=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568858108
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KENNETH REY BLAIR FNP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/10/2015
-----------------------------------------------------
Last Update Date | 04/10/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9506 HOSPITAL AVE
-----------------------------------------------------
City | NASSAWADOX
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23413
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-414-8333
-----------------------------------------------------
Fax | 757-414-8338
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 856 J CLYDE MORRIS BLVD SUITE A
-----------------------------------------------------
City | NEWPORT NEWS
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23601-1318
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-594-4006
-----------------------------------------------------
Fax | 757-534-5190
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 0024172482
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------