MEDICARE: MS. LATOYA BLACKMAN 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	163W00000X	Registered Nurse	650208	NY

General Provider Information

NPI Number	:	1669736534
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LATOYA BLACKMAN RN

Provider Business Mailing Address
First Line	:	12360 147TH ST
Second Line	:
City	:	JAMAICA
State	:	NY
Zip	:	11436-1628
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	921 MADISON AVE
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10021-3508
Country	:	US
Telephone Number	:	917-677-0723
Fax Number	:

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

Provider Enumeration Date	:	06/26/2012
Last Update Date	:	06/26/2012

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