Provider Demographics
NPI:1003870304
Name:BLANKENSHIP, STACI (OTR/L)
Entity Type:Individual
Prefix:
First Name:STACI
Middle Name:
Last Name:BLANKENSHIP
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1296
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63902-1296
Mailing Address - Country:US
Mailing Address - Phone:573-686-5439
Mailing Address - Fax:573-778-0103
Practice Address - Street 1:4358 HWY PP
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-1530
Practice Address - Country:US
Practice Address - Phone:573-686-5439
Practice Address - Fax:573-778-0103
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-13
Last Update Date:2010-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003011549225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO475775235Medicaid