Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225X00000X | Occupational Therapist | 2003011549 | MO |
NPI | 1003870304 |
---|---|
Provider Name | Staci Blankenship |
First Address | Poplar Bluff, MO 63902-1296 |
Second Address | Poplar Bluff, MO 63901-1530 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 13/04/2006 |
Last Update Date | 16/09/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
475775235 | (05) | MO |