Provider Demographics
NPI:1891793220
Name:DEWALD, CAROL BLANKEMEYER (MSN)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:BLANKEMEYER
Last Name:DEWALD
Suffix:
Gender:F
Credentials:MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4075 OLD WESTERN ROW RD
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:OH
Mailing Address - Zip Code:45040-3104
Mailing Address - Country:US
Mailing Address - Phone:513-536-0602
Mailing Address - Fax:
Practice Address - Street 1:4075 OLD WESTERN ROW RD
Practice Address - Street 2:
Practice Address - City:MASON
Practice Address - State:OH
Practice Address - Zip Code:45040-3104
Practice Address - Country:US
Practice Address - Phone:513-536-0602
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN202899163WP0809X
OHNS-01520364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2399622Medicaid
OH02061Medicare PIN
OH890001031Medicare PIN
P43260Medicare UPIN