Provider Demographics
NPI:1639107824
Name:BLANTON, RENAE (ANP)
Entity Type:Individual
Prefix:
First Name:RENAE
Middle Name:
Last Name:BLANTON
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 39368
Mailing Address - Street 2:
Mailing Address - City:NINILCHIK
Mailing Address - State:AK
Mailing Address - Zip Code:99639-0368
Mailing Address - Country:US
Mailing Address - Phone:907-567-3970
Mailing Address - Fax:907-567-3902
Practice Address - Street 1:15765 KINGSLEY RD
Practice Address - Street 2:
Practice Address - City:NINILCHIK
Practice Address - State:AK
Practice Address - Zip Code:99639-9759
Practice Address - Country:US
Practice Address - Phone:907-567-3970
Practice Address - Fax:907-567-3902
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK706363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1619001Medicaid