Healthcare Provider Details

I. General information

NPI: 1609930015
Provider Name (Legal Business Name): MARYELLEN BLANK NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 10/17/2024
Certification Date: 10/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 4TH AVE
BAY SHORE NY
11706-7908
US

IV. Provider business mailing address

170 DRIFTWOOD DR
WEST ISLIP NY
11795-5002
US

V. Phone/Fax

Practice location:
  • Phone: 631-665-6707
  • Fax: 631-665-3564
Mailing address:
  • Phone: 631-422-7362
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License Number400620
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberF400620-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: