Provider Demographics
NPI:1295210367
Name:BLANKENSHIP, LAURA R
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:R
Last Name:BLANKENSHIP
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:940 HOLLY ST
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29115-4930
Mailing Address - Country:US
Mailing Address - Phone:803-536-2725
Mailing Address - Fax:803-534-3118
Practice Address - Street 1:940 HOLLY ST
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29115-4930
Practice Address - Country:US
Practice Address - Phone:803-536-2725
Practice Address - Fax:803-534-3118
Is Sole Proprietor?:No
Enumeration Date:2018-09-25
Last Update Date:2020-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC22250363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics