Provider Demographics
NPI:1982717484
Name:BLANKENSHIP, KELLY DAWN (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:DAWN
Last Name:BLANKENSHIP
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MEDICAL CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27157-0001
Mailing Address - Country:US
Mailing Address - Phone:336-716-2255
Mailing Address - Fax:336-716-3202
Practice Address - Street 1:1249 15TH ST
Practice Address - Street 2:SUITE 4093
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-3662
Practice Address - Country:US
Practice Address - Phone:304-691-8714
Practice Address - Fax:304-691-8591
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2018-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1973363AM0700X
NC103658363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00247717OtherRAILROAD MEDICARE
SC0251PAMedicaid
P00247717OtherRAILROAD MEDICARE
NC2757232CMedicare ID - Type Unspecified