Provider Demographics
NPI:1821779489
Name:BLAIR, JAMIE
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:BLAIR
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 1:201 PARK ST
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-1708
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:484 GOLDEN AUTUMN WAY STE 201
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42103-6914
Practice Address - Country:US
Practice Address - Phone:270-781-5111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-27
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KY4007596363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program