Provider Demographics
NPI:1851177554
Name:BLANTON, KAYLA MOODY
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:MOODY
Last Name:BLANTON
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 1:151 WHISPERING OAKS DR
Mailing Address - Street 2:
Mailing Address - City:LONGS
Mailing Address - State:SC
Mailing Address - Zip Code:29568-6959
Mailing Address - Country:US
Mailing Address - Phone:843-627-1111
Mailing Address - Fax:
Practice Address - Street 1:164 WACCAMAW MEDICAL PARK
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-8903
Practice Address - Country:US
Practice Address - Phone:843-234-4888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-07
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC237170163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management