Provider Demographics
NPI:1255650883
Name:BLAINE, PAMELA GAIL (LMT)
Entity Type:Individual
Prefix:MS
First Name:PAMELA
Middle Name:GAIL
Last Name:BLAINE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1411 OAK KNOLL DR
Mailing Address - Street 2:
Mailing Address - City:BARDSTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40004-9345
Mailing Address - Country:US
Mailing Address - Phone:502-348-1925
Mailing Address - Fax:
Practice Address - Street 1:1411 OAK KNOLL DR
Practice Address - Street 2:
Practice Address - City:BARDSTOWN
Practice Address - State:KY
Practice Address - Zip Code:40004-9345
Practice Address - Country:US
Practice Address - Phone:502-348-1925
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-21
Last Update Date:2010-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY0039225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist