Provider Demographics
NPI:1821472085
Name:BLANKS, TAMICA
Entity Type:Individual
Prefix:
First Name:TAMICA
Middle Name:
Last Name:BLANKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2853 REVELS AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45417-4226
Mailing Address - Country:US
Mailing Address - Phone:937-321-1705
Mailing Address - Fax:
Practice Address - Street 1:2853 REVELS AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45417
Practice Address - Country:US
Practice Address - Phone:937-321-1705
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-16
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH401746600515376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide