Provider Demographics
NPI:1831406644
Name:BLANKENSHIP, CRYSTAL LYNN (MASSAGE THERAPIST)
Entity type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:LYNN
Last Name:BLANKENSHIP
Suffix:
Gender:F
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 GARRARD RD
Mailing Address - Street 2:
Mailing Address - City:FORT MEADE
Mailing Address - State:FL
Mailing Address - Zip Code:33841-9534
Mailing Address - Country:US
Mailing Address - Phone:863-440-1535
Mailing Address - Fax:
Practice Address - Street 1:1200 W AVON BLVD
Practice Address - Street 2:
Practice Address - City:AVON PARK
Practice Address - State:FL
Practice Address - Zip Code:33825-8343
Practice Address - Country:US
Practice Address - Phone:863-440-1535
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-01
Last Update Date:2010-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA59595175L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175L00000XOther Service ProvidersHomeopath
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMA 59550OtherMASSAGE STATE ID