Provider Demographics
NPI:1508257221
Name:BLANKENBECKLER, SHANNON (AGNP-C, PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:BLANKENBECKLER
Suffix:
Gender:F
Credentials:AGNP-C, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 LAVEEN WAY
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28412-2697
Mailing Address - Country:US
Mailing Address - Phone:910-470-8496
Mailing Address - Fax:
Practice Address - Street 1:2909 MARKET ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-1221
Practice Address - Country:US
Practice Address - Phone:910-795-2118
Practice Address - Fax:910-795-2318
Is Sole Proprietor?:No
Enumeration Date:2015-02-17
Last Update Date:2022-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCBLAN-GIKLC9363LA2200X
NC5007563363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health