Healthcare Provider Details

I. General information

NPI: 1538100490
Provider Name (Legal Business Name): LESLIE R BLATT APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 10/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 YORK ST
NEW HAVEN CT
06511-4405
US

IV. Provider business mailing address

104 BAILEY DR
NORTH BRANFORD CT
06471-1441
US

V. Phone/Fax

Practice location:
  • Phone: 203-688-9277
  • Fax:
Mailing address:
  • Phone: 203-483-5149
  • Fax: 203-483-5149

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License Number001751
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License Number001751
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: