Provider Demographics
NPI:1194041525
Name:BLANKENSHIP, KHRYSTAL (BHRS)
Entity Type:Individual
Prefix:
First Name:KHRYSTAL
Middle Name:
Last Name:BLANKENSHIP
Suffix:
Gender:F
Credentials:BHRS
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 662
Mailing Address - Street 2:
Mailing Address - City:PURCELL
Mailing Address - State:OK
Mailing Address - Zip Code:73080-0662
Mailing Address - Country:US
Mailing Address - Phone:405-527-1785
Mailing Address - Fax:405-527-1084
Practice Address - Street 1:314 S BROADWAY AVE
Practice Address - Street 2:SUITE 106
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-5828
Practice Address - Country:US
Practice Address - Phone:580-235-0210
Practice Address - Fax:580-235-0211
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-09
Last Update Date:2010-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKN/A225C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100746700CMedicaid