Healthcare Provider Details

I. General information

NPI: 1619122777
Provider Name (Legal Business Name): JESSICA E BLUM CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2008
Last Update Date: 05/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

545 1ST AVE GBH-C124
NEW YORK NY
10016-6401
US

IV. Provider business mailing address

545 1ST AVE GBH-C124
NEW YORK NY
10016-6401
US

V. Phone/Fax

Practice location:
  • Phone: 212-263-6600
  • Fax:
Mailing address:
  • Phone: 212-263-6600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberF430411-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: