Provider Demographics
NPI:1013650506
Name:BLANTON, LAURA MAE
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:MAE
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 1:1442 LEITER RD
Mailing Address - Street 2:
Mailing Address - City:LUCAS
Mailing Address - State:OH
Mailing Address - Zip Code:44843-9539
Mailing Address - Country:US
Mailing Address - Phone:419-566-4085
Mailing Address - Fax:
Practice Address - Street 1:1221 S TRIMBLE RD
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44907-2200
Practice Address - Country:US
Practice Address - Phone:419-951-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-14
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.428476363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health