Healthcare Provider Details

I. General information

NPI: 1205965977
Provider Name (Legal Business Name): IRENE PATRICIA BLACKBURN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26 COURT ST SUITE 905
BROOKLYN NY
11242-0103
US

IV. Provider business mailing address

23008 146TH AVE
SPRINGFIELD GARDENS NY
11413-3917
US

V. Phone/Fax

Practice location:
  • Phone: 718-246-9238
  • Fax:
Mailing address:
  • Phone: 917-324-1223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number397881-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: