Provider Demographics
NPI:1487260154
Name:BLANTON, ANGIE MICHELE (RANK I)
Entity type:Individual
Prefix:
First Name:ANGIE
Middle Name:MICHELE
Last Name:BLANTON
Suffix:
Gender:F
Credentials:RANK I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11215 W HIGHWAY 36
Mailing Address - Street 2:
Mailing Address - City:SHARPSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:40374-9626
Mailing Address - Country:US
Mailing Address - Phone:859-274-3313
Mailing Address - Fax:
Practice Address - Street 1:105 WINDSOR PATH
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:KY
Practice Address - Zip Code:40324-9818
Practice Address - Country:US
Practice Address - Phone:859-559-6041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-18
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst