Provider Demographics
NPI:1962805747
Name:BLANCO, STEPHANIE A (CNM)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:A
Last Name:BLANCO
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4204 BROOK RD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23227-3702
Mailing Address - Country:US
Mailing Address - Phone:517-937-5340
Mailing Address - Fax:
Practice Address - Street 1:1602 SKIPWITH RD
Practice Address - Street 2:
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23229-5205
Practice Address - Country:US
Practice Address - Phone:804-289-4530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-07
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024171391367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife