Provider Demographics
NPI:1043372725
Name:BLANKS, DYLAN (RN)
Entity Type:Individual
Prefix:MS
First Name:DYLAN
Middle Name:
Last Name:BLANKS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:DYLAN
Other - Middle Name:LAVON
Other - Last Name:BLANKS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:1530 GOODPASTURE ISLAND RD
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-1712
Mailing Address - Country:US
Mailing Address - Phone:541-465-2258
Mailing Address - Fax:541-485-8235
Practice Address - Street 1:1530 GOODPASTURE ISLAND RD
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-1712
Practice Address - Country:US
Practice Address - Phone:541-465-2258
Practice Address - Fax:541-485-8235
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR098375Medicaid