Provider Demographics
NPI:1598240145
Name:BLANDFORD, AMY JO (APRN)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:JO
Last Name:BLANDFORD
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 MULLIGAN DR
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-7639
Mailing Address - Country:US
Mailing Address - Phone:618-521-6561
Mailing Address - Fax:
Practice Address - Street 1:3333 W DEYOUNG ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-5884
Practice Address - Country:US
Practice Address - Phone:618-998-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-29
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.018153363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily