MEDICARE: PATRICIA V BLANC NURSE PRACTITIONER

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	363L00000X	Nurse Practitioner	004186	CT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4186	OTHER	CT	CT LICENSE

General Provider Information

NPI Number	:	1982837233
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PATRICIA V BLANC NURSE PRACTITIONER

Provider Business Mailing Address
First Line	:	982 E MAIN ST
Second Line	:
City	:	BRIDGEPORT
State	:	CT
Zip	:	06608-1913
Country	:	US
Telephone Number	:	203-696-3260
Fax Number	:	203-375-2318

Provider Business Practice Location Address
First Line	:	727 HONEYSPOT RD
Second Line	:
City	:	STRATFORD
State	:	CT
Zip	:	06615-7172
Country	:	US
Telephone Number	:	203-375-7242
Fax Number	:	203-375-2318

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

Provider Enumeration Date	:	09/02/2009
Last Update Date	:	04/19/2016

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