Provider Demographics
NPI:1518413087
Name:RODGERS-BLANKENSHIP, MAUNA-LOA MARQUETTE (FNP-C)
Entity Type:Individual
Prefix:
First Name:MAUNA-LOA
Middle Name:MARQUETTE
Last Name:RODGERS-BLANKENSHIP
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72549 HIGHWAY 111
Mailing Address - Street 2:
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92260-3306
Mailing Address - Country:US
Mailing Address - Phone:760-340-9158
Mailing Address - Fax:
Practice Address - Street 1:72549 HIGHWAY 111
Practice Address - Street 2:
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92260-3306
Practice Address - Country:US
Practice Address - Phone:760-340-9158
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-25
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95004020363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1518413087Medicaid
CA95004020Medicaid
CA1518413087OtherFNP-C