Provider Demographics
NPI:1932420239
Name:BLANDAMER, MILDRED A (PMHNP-BC)
Entity Type:Individual
Prefix:MS
First Name:MILDRED
Middle Name:A
Last Name:BLANDAMER
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:MS
Other - First Name:MILDRED (MIDGE)
Other - Middle Name:A
Other - Last Name:BLANDAMER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PMHCNS/CRNP-BC
Mailing Address - Street 1:1201 HERITAGE CIR
Mailing Address - Street 2:
Mailing Address - City:PAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74058-3744
Mailing Address - Country:US
Mailing Address - Phone:918-762-6604
Mailing Address - Fax:918-762-6646
Practice Address - Street 1:1201 HERITAGE CIR
Practice Address - Street 2:
Practice Address - City:PAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74058-3744
Practice Address - Country:US
Practice Address - Phone:918-762-6604
Practice Address - Fax:918-762-6646
Is Sole Proprietor?:No
Enumeration Date:2010-06-21
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0034370363LP0808X
GARN147204363LP0808X, 364SP0809X
AL1-098488363LP0808X, 364SP0809X
MN5400363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult