Provider Demographics
NPI:1356432744
Name:BLANKENSHIP, LISA D (MD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:D
Last Name:BLANKENSHIP
Suffix:
Gender:F
Credentials:MD
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 4000 (117)
Mailing Address - Street 2:PM&RS
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:TN
Mailing Address - Zip Code:37684
Mailing Address - Country:US
Mailing Address - Phone:423-926-1171
Mailing Address - Fax:
Practice Address - Street 1:DOGWOOD AVE
Practice Address - Street 2:VAMC
Practice Address - City:MOUNTAIN HOME
Practice Address - State:TN
Practice Address - Zip Code:63684
Practice Address - Country:US
Practice Address - Phone:423-926-1171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2010-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200100642208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89129E9Medicaid
NCG82956Medicare UPIN
NC89129E9Medicaid