Healthcare Provider Details

I. General information

NPI: 1366140873
Provider Name (Legal Business Name): KATTIA BLANCO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATTIA BLANCO LORIA MD

II. Dates (important events)

Enumeration Date: 02/23/2023
Last Update Date: 08/21/2024
Certification Date: 08/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 S FLA ST
BUSHNELL FL
33513-6703
US

IV. Provider business mailing address

2238 SOUTHWOOD DR
THE VILLAGES FL
32162-3845
US

V. Phone/Fax

Practice location:
  • Phone: 404-775-4390
  • Fax:
Mailing address:
  • Phone: 404-775-4390
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberACN1642
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: