Provider Demographics
NPI:1194096446
Name:BLANKENSHIP, CAROLYN GWENDOLYN (PTA)
Entity type:Individual
Prefix:MRS
First Name:CAROLYN
Middle Name:GWENDOLYN
Last Name:BLANKENSHIP
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:445 RICHARDSON RD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:TN
Mailing Address - Zip Code:37083-3813
Mailing Address - Country:US
Mailing Address - Phone:615-699-2495
Mailing Address - Fax:
Practice Address - Street 1:445 RICHARDSON RD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:TN
Practice Address - Zip Code:37083-3813
Practice Address - Country:US
Practice Address - Phone:615-699-2495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-18
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN478225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant