Provider Demographics
NPI:1184662280
Name:BLASINGAME, KIMBERLY PATTON (CNM)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:PATTON
Last Name:BLASINGAME
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 658
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30503-0658
Mailing Address - Country:US
Mailing Address - Phone:770-718-1122
Mailing Address - Fax:770-534-8998
Practice Address - Street 1:725 JESSE JEWELL PKWY SE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3834
Practice Address - Country:US
Practice Address - Phone:770-297-2200
Practice Address - Fax:770-534-8139
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2011-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN093785367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000773649JMedicaid
GA000773649FMedicaid
GA000773649KMedicaid
GA329086OtherWELLCARE
GA10044863OtherAMERIGROUP