Provider Demographics
NPI:1871999292
Name:BLANTON, BRANDI L (CNP)
Entity type:Individual
Prefix:
First Name:BRANDI
Middle Name:L
Last Name:BLANTON
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 N COLUMBUS ST
Mailing Address - Street 2:
Mailing Address - City:CRESTLINE
Mailing Address - State:OH
Mailing Address - Zip Code:44827-1455
Mailing Address - Country:US
Mailing Address - Phone:419-468-0522
Mailing Address - Fax:
Practice Address - Street 1:1323 E MANSFIELD ST
Practice Address - Street 2:
Practice Address - City:BUCYRUS
Practice Address - State:OH
Practice Address - Zip Code:44820-1960
Practice Address - Country:US
Practice Address - Phone:419-563-0300
Practice Address - Fax:419-563-0500
Is Sole Proprietor?:No
Enumeration Date:2014-11-12
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.16051363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0113714Medicaid