Provider Demographics
NPI:1871898866
Name:RICHARDSON, BLAIR (CRNA)
Entity type:Individual
Prefix:MISS
First Name:BLAIR
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:MRS
Other - First Name:BLAIR
Other - Middle Name:
Other - Last Name:BRUCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:639 NORTH MULBERRY STREET
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-1931
Mailing Address - Country:US
Mailing Address - Phone:270-737-4600
Mailing Address - Fax:270-737-1722
Practice Address - Street 1:639 NORTH MULBERRY STREET
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-1931
Practice Address - Country:US
Practice Address - Phone:270-737-4600
Practice Address - Fax:270-737-1722
Is Sole Proprietor?:No
Enumeration Date:2011-01-21
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY085894367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100154900Medicaid
KY7100154900Medicaid