Provider Demographics
NPI:1780565614
Name:BLANTON, ALEXANDRA NICOLE
Entity type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:NICOLE
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 1:345 W MADISON ST
Mailing Address - Street 2:
Mailing Address - City:STARKE
Mailing Address - State:FL
Mailing Address - Zip Code:32091-3923
Mailing Address - Country:US
Mailing Address - Phone:904-964-5455
Mailing Address - Fax:904-964-4099
Practice Address - Street 1:345 W MADISON ST
Practice Address - Street 2:
Practice Address - City:STARKE
Practice Address - State:FL
Practice Address - Zip Code:32091-3923
Practice Address - Country:US
Practice Address - Phone:904-964-5455
Practice Address - Fax:904-964-4099
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-09
Last Update Date:2025-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11041266363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily