Provider Demographics
NPI:1366191355
Name:BLANKLEY, BETH Y (NP-BC)
Entity type:Individual
Prefix:MRS
First Name:BETH
Middle Name:Y
Last Name:BLANKLEY
Suffix:
Gender:F
Credentials:NP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 WASHINGTON SQUARE SHOPPING CTR
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63090-5343
Mailing Address - Country:US
Mailing Address - Phone:636-390-1777
Mailing Address - Fax:636-390-1778
Practice Address - Street 1:555 WASHINGTON SQUARE SHOPPING CTR
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:MO
Practice Address - Zip Code:63090-5343
Practice Address - Country:US
Practice Address - Phone:636-390-1777
Practice Address - Fax:636-390-1778
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-18
Last Update Date:2022-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002013536163W00000X
IL041337230163W00000X
MO2021051162363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse