Provider Demographics
NPI:1093597387
Name:BLANKENSHIP, GAGE
Entity Type:Individual
Prefix:
First Name:GAGE
Middle Name:
Last Name:BLANKENSHIP
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1707 LINWOOD DR STE G1707
Mailing Address - Street 2:
Mailing Address - City:PARAGOULD
Mailing Address - State:AR
Mailing Address - Zip Code:72450-5364
Mailing Address - Country:US
Mailing Address - Phone:870-604-4455
Mailing Address - Fax:
Practice Address - Street 1:1707 LINWOOD DR STE G1707
Practice Address - Street 2:
Practice Address - City:PARAGOULD
Practice Address - State:AR
Practice Address - Zip Code:72450-5364
Practice Address - Country:US
Practice Address - Phone:870-604-4455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-20
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator