Provider Demographics
NPI:1750988192
Name:BLANKENSHIP, SHANNON RENEE
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:RENEE
Last Name:BLANKENSHIP
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 1:14341 GENERATION LN
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23838-4200
Mailing Address - Country:US
Mailing Address - Phone:804-243-4603
Mailing Address - Fax:
Practice Address - Street 1:14341 GENERATION LN
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23838-4200
Practice Address - Country:US
Practice Address - Phone:804-243-4603
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-08
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
224ZE0001X, 171W00000X
ND225XE0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
No224ZE0001XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantEnvironmental Modification
No225XE0001XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistEnvironmental Modification