Provider Demographics
NPI:1588332324
Name:BLANK, MAKAYLA STEPHANIE (PTA)
Entity type:Individual
Prefix:
First Name:MAKAYLA
Middle Name:STEPHANIE
Last Name:BLANK
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 1:1887 N 150TH PLZ
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68154-1055
Mailing Address - Country:US
Mailing Address - Phone:402-210-5920
Mailing Address - Fax:
Practice Address - Street 1:7915 N 30TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68112-2418
Practice Address - Country:US
Practice Address - Phone:402-827-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-04
Last Update Date:2021-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1838225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant