Provider Demographics
NPI:1679594683
Name:BLASINGAME, MARY E (RNP,APN)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:E
Last Name:BLASINGAME
Suffix:
Gender:F
Credentials:RNP,APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:982 WINE DOT RD
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:AR
Mailing Address - Zip Code:72104-7551
Mailing Address - Country:US
Mailing Address - Phone:501-337-0840
Mailing Address - Fax:501-332-6889
Practice Address - Street 1:2204 E SULLENBERGER AVE
Practice Address - Street 2:
Practice Address - City:MALVERN
Practice Address - State:AR
Practice Address - Zip Code:72104-4806
Practice Address - Country:US
Practice Address - Phone:501-332-6972
Practice Address - Fax:501-332-6889
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP01165363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health