Provider Demographics
NPI:1013120435
Name:BLANKENSHIP, AMANDA K (LMP, NCTMB)
Entity Type:Individual
Prefix:MISS
First Name:AMANDA
Middle Name:K
Last Name:BLANKENSHIP
Suffix:
Gender:F
Credentials:LMP, NCTMB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1568 NORTHWOOD DR APT 2
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-8317
Mailing Address - Country:US
Mailing Address - Phone:509-330-0771
Mailing Address - Fax:
Practice Address - Street 1:700 S MAIN ST
Practice Address - Street 2:GRITMAN MEDICAL CENTER
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-3056
Practice Address - Country:US
Practice Address - Phone:208-883-6544
Practice Address - Fax:208-883-6452
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00017159225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist