Provider Demographics
NPI:1174876247
Name:BLEVINS, BRENT M (RN, RRT,MS)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:M
Last Name:BLEVINS
Suffix:
Gender:M
Credentials:RN, RRT,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 KYLE MALIA RDG
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41102-7960
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:141 KYLE MALIA RDG
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41102-7960
Practice Address - Country:US
Practice Address - Phone:304-399-4969
Practice Address - Fax:304-399-4969
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-26
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV59357163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool