Provider Demographics
NPI:1285638551
Name:BLODGETT, VICKI D (CRNA)
Entity Type:Individual
Prefix:
First Name:VICKI
Middle Name:D
Last Name:BLODGETT
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 N 4TH AVE E
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:IA
Mailing Address - Zip Code:50208-3135
Mailing Address - Country:US
Mailing Address - Phone:641-792-1273
Mailing Address - Fax:641-791-4852
Practice Address - Street 1:204 N 4TH AVE E
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:IA
Practice Address - Zip Code:50208-3135
Practice Address - Country:US
Practice Address - Phone:641-792-1273
Practice Address - Fax:641-791-4852
Is Sole Proprietor?:No
Enumeration Date:2005-06-02
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAD-103442367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0438531Medicaid
IA19813OtherBCBS PROVIDER #
IA19813OtherBCBS PROVIDER #