Provider Demographics
NPI:1043809130
Name:BLANKENSHIP, LATARA EASTON
Entity Type:Individual
Prefix:
First Name:LATARA
Middle Name:EASTON
Last Name:BLANKENSHIP
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1205 N MARKET AVE
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74801-4923
Mailing Address - Country:US
Mailing Address - Phone:580-791-1005
Mailing Address - Fax:
Practice Address - Street 1:3903 N HARRISON ST
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74804-1426
Practice Address - Country:US
Practice Address - Phone:405-585-2971
Practice Address - Fax:405-585-2983
Is Sole Proprietor?:No
Enumeration Date:2021-01-13
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2224224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK2224OtherSTATE LICENSE