=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881323673
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KALLEN BLANKENBURG SLAVENS FNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/07/2022
-----------------------------------------------------
Last Update Date | 07/24/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 29 TIGER TRL
-----------------------------------------------------
City | RINGGOLD
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30736-2024
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-935-2254
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13570 N MAIN ST
-----------------------------------------------------
City | TRENTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30752-2012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 216119
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | GAA-NP000859
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------