Provider Demographics
NPI:1013325414
Name:BLANK, KERISSA DINAE
Entity Type:Individual
Prefix:MISS
First Name:KERISSA
Middle Name:DINAE
Last Name:BLANK
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 1:13513 FIVE POINTS MOWRYSTOWN RD
Mailing Address - Street 2:
Mailing Address - City:SARDINIA
Mailing Address - State:OH
Mailing Address - Zip Code:45171-8307
Mailing Address - Country:US
Mailing Address - Phone:937-515-5042
Mailing Address - Fax:
Practice Address - Street 1:13513 FIVE POINTS MOWRYSTOWN RD
Practice Address - Street 2:
Practice Address - City:SARDINIA
Practice Address - State:OH
Practice Address - Zip Code:45171-8307
Practice Address - Country:US
Practice Address - Phone:937-515-5042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-29
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide