Healthcare Provider Details

I. General information

NPI: 1104817501
Provider Name (Legal Business Name): ELAINE M BLECKLEY NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 10/03/2024
Certification Date: 10/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

223 CHIEF JUSTICE CUSHING HWY STE 101
COHASSET MA
02025-1391
US

IV. Provider business mailing address

PO BOX 68
S WEYMOUTH MA
02190-0001
US

V. Phone/Fax

Practice location:
  • Phone: 781-383-6800
  • Fax: 781-383-6504
Mailing address:
  • Phone: 780-803-2786
  • Fax: 781-812-1631

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number189296
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0347230
Identifier TypeMEDICAID
Identifier StateMA
Identifier Issuer
# 2
IdentifierNP9824
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerBCBS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: