Provider Demographics
NPI:1104489111
Name:BLAIR, MICHELLE RAE (NP-C)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RAE
Last Name:BLAIR
Suffix:
Gender:F
Credentials:NP-C
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 639917
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-9917
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8161 WARREN H ABERNATHY HWY
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29301-2451
Practice Address - Country:US
Practice Address - Phone:864-586-1152
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-16
Last Update Date:2024-01-03
Deactivation Date:2019-05-02
Deactivation Code:
Reactivation Date:2019-06-03
Provider Licenses
StateLicense IDTaxonomies
VA0024177529363LF0000X
SC24897363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP7525Medicaid
SCSCK1055019OtherMEDICARE PIN
SCSCK1056084OtherMEDICARE PIN
SCSCK1056067OtherMEDICARE PIN
SCSCK105J577OtherMEDICARE PIN