MEDICARE: MRS. GRACIAICA BLAISE RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	317249-1	NY

General Provider Information

NPI Number	:	1144626854
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. GRACIAICA BLAISE RN

Provider Business Mailing Address
First Line	:	1014 E 82ND ST APT 3
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11236-4224
Country	:	US
Telephone Number	:	347-347-0215
Fax Number	:

Provider Business Practice Location Address
First Line	:	6826 AVENUE L
Second Line	:	APT 2
City	:	BROOKLYN
State	:	NY
Zip	:	11234-5981
Country	:	US
Telephone Number	:	347-347-0215
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/06/2014
Last Update Date	:	07/03/2019

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