Provider Demographics
NPI:1790711042
Name:BLANKENSHIP, KRYSTI M (NP)
Entity Type:Individual
Prefix:
First Name:KRYSTI
Middle Name:M
Last Name:BLANKENSHIP
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KRYSTI
Other - Middle Name:M
Other - Last Name:REA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 3810
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64803-3810
Mailing Address - Country:US
Mailing Address - Phone:417-347-5001
Mailing Address - Fax:417-347-2477
Practice Address - Street 1:1102 W 32ND ST STE 200
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-3503
Practice Address - Country:US
Practice Address - Phone:417-347-5001
Practice Address - Fax:417-347-2477
Is Sole Proprietor?:No
Enumeration Date:2006-06-25
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO137978363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200371410AMedicaid
MO206859OtherANTHEM
OK2000779010AMedicaid
P00309838OtherRR MEDICARE
MO428336002Medicaid
P00309838OtherRR MEDICARE
Q67867Medicare UPIN