Provider Demographics
NPI:1023574704
Name:WIENTJES, BLAIR BAILEY (APRN)
Entity Type:Individual
Prefix:
First Name:BLAIR
Middle Name:BAILEY
Last Name:WIENTJES
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3101 PARISA DR
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-4584
Mailing Address - Country:US
Mailing Address - Phone:270-444-8477
Mailing Address - Fax:270-444-8479
Practice Address - Street 1:3101 PARISA DR
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-4584
Practice Address - Country:US
Practice Address - Phone:270-444-8477
Practice Address - Fax:270-444-8479
Is Sole Proprietor?:No
Enumeration Date:2019-02-18
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3013291363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner