Provider Demographics
NPI:1104372952
Name:BLANKS, AMY (CRNA)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:BLANKS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:MRS
Other - First Name:AMY
Other - Middle Name:
Other - Last Name:BLANKS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CRNA
Mailing Address - Street 1:13959 S 95TH AVE
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-1204
Mailing Address - Country:US
Mailing Address - Phone:843-615-3535
Mailing Address - Fax:
Practice Address - Street 1:13959 95TH AVENUE
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462
Practice Address - Country:US
Practice Address - Phone:843-615-3535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-31
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209014650367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered