MEDICARE: ROBIN MADONNA BLAIZE

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	163WP0809X	Adult Psychiatric/Mental Health Registered Nurse	755337	NY
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	F404761	NY

General Provider Information

NPI Number	:	1639821598
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROBIN MADONNA BLAIZE

Provider Business Mailing Address
First Line	:	518 BEACH 32ND ST
Second Line	:
City	:	FAR ROCKAWAY
State	:	NY
Zip	:	11691-1933
Country	:	US
Telephone Number	:	347-933-8383
Fax Number	:

Provider Business Practice Location Address
First Line	:	3425 VERNON BLVD
Second Line	:
City	:	ASTORIA
State	:	NY
Zip	:	11106-5121
Country	:	US
Telephone Number	:	844-815-1508
Fax Number	:

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

Provider Enumeration Date	:	01/21/2022
Last Update Date	:	07/06/2023

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