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General NPI Number Information
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NPI Number | 1609930015
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Entity Type | Individual
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Provider Name | MARYELLEN BLANK NP
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Gender | Female
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Dates
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Enumeration Date | 12/20/2006
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Last Update Date | 10/17/2024
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Provider Practice Location Address
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Address Line | 21 4TH AVE
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City | BAY SHORE
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State | NY
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Zip | 11706-7908
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Country | US
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Telephone | 631-665-6707
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Fax | 631-665-3564
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Provider Business Mailing Address
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Address Line | 170 DRIFTWOOD DR
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City | WEST ISLIP
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State | NY
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Zip | 11795-5002
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Country | US
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Telephone | 631-422-7362
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 364SP0809X
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Taxonomy Name | Adult Psychiatric/Mental Health Clinical Nurse Specialist
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License Number | 400620
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | F400620-01
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License Number State | NY
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