Provider Demographics
NPI:1538511290
Name:COREY, BLYTH (RN)
Entity Type:Individual
Prefix:
First Name:BLYTH
Middle Name:
Last Name:COREY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:149 CRESTMONT CIR
Mailing Address - Street 2:
Mailing Address - City:GROVER
Mailing Address - State:MO
Mailing Address - Zip Code:63040-1623
Mailing Address - Country:US
Mailing Address - Phone:636-577-2987
Mailing Address - Fax:
Practice Address - Street 1:1004 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:UNIVERSITY CITY
Practice Address - State:MO
Practice Address - Zip Code:63130-2325
Practice Address - Country:US
Practice Address - Phone:314-240-5613
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-06
Last Update Date:2016-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008023234163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse