Provider Demographics
NPI:1538405154
Name:BLANKENSHIP CLARK, ANN ELIZABETH (PA)
Entity type:Individual
Prefix:MS
First Name:ANN
Middle Name:ELIZABETH
Last Name:BLANKENSHIP CLARK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 RIDGEFIELD DR
Mailing Address - Street 2:
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27517-8661
Mailing Address - Country:US
Mailing Address - Phone:704-293-6312
Mailing Address - Fax:
Practice Address - Street 1:1031 W WILLIAMS ST
Practice Address - Street 2:
Practice Address - City:APEX
Practice Address - State:NC
Practice Address - Zip Code:27502-3955
Practice Address - Country:US
Practice Address - Phone:919-363-0190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-31
Last Update Date:2012-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL003116133V00000X
NC0010-03932363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered