Provider Demographics
NPI:1891267886
Name:BLAKLEY, MEGAN RENEE (NP)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:RENEE
Last Name:BLAKLEY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 232
Mailing Address - Street 2:
Mailing Address - City:GARDEN PLAIN
Mailing Address - State:KS
Mailing Address - Zip Code:67050-0232
Mailing Address - Country:US
Mailing Address - Phone:316-644-0249
Mailing Address - Fax:
Practice Address - Street 1:501 N MAIZE RD
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67212-4655
Practice Address - Country:US
Practice Address - Phone:316-721-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-01
Last Update Date:2019-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS78357363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily