Provider Demographics
NPI:1104292895
Name:BLASSINGAME, KATHERINE ROSE (CFNP)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:ROSE
Last Name:BLASSINGAME
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:968 ROAD 2578
Mailing Address - Street 2:
Mailing Address - City:BALDWYN
Mailing Address - State:MS
Mailing Address - Zip Code:38824-7874
Mailing Address - Country:US
Mailing Address - Phone:662-397-3057
Mailing Address - Fax:
Practice Address - Street 1:117 FAIRFIELD DR
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:MS
Practice Address - Zip Code:38652-3107
Practice Address - Country:US
Practice Address - Phone:662-534-0029
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-17
Last Update Date:2015-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR891627363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner