Provider Demographics
NPI:1942859251
Name:BLANK, CHRISTINE O'REILLY (CAA)
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:O'REILLY
Last Name:BLANK
Suffix:
Gender:F
Credentials:CAA
Other - Prefix:
Other - First Name:CHRISTINE
Other - Middle Name:KATHERINE
Other - Last Name:O'REILLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CAA
Mailing Address - Street 1:96 RAINBOW TROUT LN
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA
Mailing Address - State:FL
Mailing Address - Zip Code:32081-1213
Mailing Address - Country:US
Mailing Address - Phone:404-441-9395
Mailing Address - Fax:
Practice Address - Street 1:1 SHIRCLIFF WAY
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4748
Practice Address - Country:US
Practice Address - Phone:904-308-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-09
Last Update Date:2025-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
367H00000X
FLAA520367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAA520Medicaid