Provider Demographics
NPI:1477289080
Name:BLANKENSHIP, KATRINA (PRSS)
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:
Last Name:BLANKENSHIP
Suffix:
Gender:F
Credentials:PRSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 LOGAN ST STE 201
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSON
Mailing Address - State:WV
Mailing Address - Zip Code:25661-3630
Mailing Address - Country:US
Mailing Address - Phone:304-235-3570
Mailing Address - Fax:304-235-2654
Practice Address - Street 1:101 LOGAN ST STE 201
Practice Address - Street 2:
Practice Address - City:WILLIAMSON
Practice Address - State:WV
Practice Address - Zip Code:25661-3630
Practice Address - Country:US
Practice Address - Phone:304-235-3570
Practice Address - Fax:304-235-2654
Is Sole Proprietor?:No
Enumeration Date:2022-07-26
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171400000X, 171M00000X
WV14-904175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No171400000XOther Service ProvidersHealth & Wellness Coach
No171M00000XOther Service ProvidersCase Manager/Care Coordinator