Healthcare Provider Details

I. General information

NPI: 1023730132
Provider Name (Legal Business Name): LARISSA BLENKER RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2022
Last Update Date: 09/15/2022
Certification Date: 09/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

71 LORRAINE AVE
BUFFALO NY
14220-1740
US

IV. Provider business mailing address

5160 WILLIAM ST
LANCASTER NY
14086-9405
US

V. Phone/Fax

Practice location:
  • Phone: 716-816-4570
  • Fax:
Mailing address:
  • Phone: 716-982-5835
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number659311
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: