Provider Demographics
NPI:1194802561
Name:BLANK, MARILYN K (RN, BN, MSN)
Entity type:Individual
Prefix:
First Name:MARILYN
Middle Name:K
Last Name:BLANK
Suffix:
Gender:F
Credentials:RN, BN, MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 N JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:PANDORA
Mailing Address - State:OH
Mailing Address - Zip Code:45877-9414
Mailing Address - Country:US
Mailing Address - Phone:419-384-3050
Mailing Address - Fax:
Practice Address - Street 1:1303 BELLEFONTAINE AVE
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45804-3109
Practice Address - Country:US
Practice Address - Phone:419-222-5788
Practice Address - Fax:419-222-9504
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN187417163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health