Healthcare Provider Details

I. General information

NPI: 1104605625
Provider Name (Legal Business Name): MIRTHA LIDIA BLANCO APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2023
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

560 W 168TH ST
NEW YORK NY
10032-3917
US

IV. Provider business mailing address

560 W 168YH STREET
NEW YORK NY
10032
US

V. Phone/Fax

Practice location:
  • Phone: 212-564-5756
  • Fax:
Mailing address:
  • Phone: 212-305-5756
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11028794
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: