Healthcare Provider Details

I. General information

NPI: 1659721579
Provider Name (Legal Business Name): TERESSA BLANCHARD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2016
Last Update Date: 03/18/2021
Certification Date: 03/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1865 TAMARACK RD
NEWARK OH
43055
US

IV. Provider business mailing address

1865 TAMARACK RD
NEWARK OH
43055
US

V. Phone/Fax

Practice location:
  • Phone: 220-564-4934
  • Fax: 220-564-4944
Mailing address:
  • Phone: 220-564-4934
  • Fax: 220-564-4944

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberAPRN.CNP.19268
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCOA.19268-NP
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: