Provider Demographics
NPI:1740867498
Name:BLANTON, ELIZABETH KAYLOR
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:KAYLOR
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 1:416 E MAUMEE ST
Mailing Address - Street 2:
Mailing Address - City:ANGOLA
Mailing Address - State:IN
Mailing Address - Zip Code:46703-2015
Mailing Address - Country:US
Mailing Address - Phone:260-667-5131
Mailing Address - Fax:
Practice Address - Street 1:1500 W MAUMEE ST
Practice Address - Street 2:
Practice Address - City:ANGOLA
Practice Address - State:IN
Practice Address - Zip Code:46703-8605
Practice Address - Country:US
Practice Address - Phone:606-658-4942
Practice Address - Fax:260-668-5690
Is Sole Proprietor?:No
Enumeration Date:2021-03-27
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02007711A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine