Healthcare Provider Details

I. General information

NPI: 1033193768
Provider Name (Legal Business Name): JESSICA BLUE NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2005
Last Update Date: 01/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26 BLEECKER ST
NEW YORK NY
10012-2413
US

IV. Provider business mailing address

26 BLEECKER ST
NEW YORK NY
10012-2413
US

V. Phone/Fax

Practice location:
  • Phone: 212-274-7250
  • Fax:
Mailing address:
  • Phone: 212-274-7250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberF420760
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: