Provider Demographics
NPI:1356358477
Name:BLANKENSHIP, MARY LOUISE (RN, FNP, PMHNP-BC)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:LOUISE
Last Name:BLANKENSHIP
Suffix:
Gender:F
Credentials:RN, FNP, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1907 NW 6TH ST
Mailing Address - Street 2:
Mailing Address - City:HERMISTON
Mailing Address - State:OR
Mailing Address - Zip Code:97838-1148
Mailing Address - Country:US
Mailing Address - Phone:972-825-2575
Mailing Address - Fax:
Practice Address - Street 1:3188 SOUTHERN BLVD SE STE B1
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-1989
Practice Address - Country:US
Practice Address - Phone:505-200-9158
Practice Address - Fax:505-200-9497
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0375722363LP2300X
NM2023150476363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3017279-01Medicaid
NM77056396Medicaid
TXP80380Medicare UPIN