MEDICARE: LYNESE JENNINGS-BLAZER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	199107	NY

General Provider Information

NPI Number	:	1316542038
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LYNESE JENNINGS-BLAZER

Provider Business Mailing Address
First Line	:	2371 N FOREST RD APT 310
Second Line	:
City	:	AMHERST
State	:	NY
Zip	:	14068-1067
Country	:	US
Telephone Number	:	716-563-1179
Fax Number	:

Provider Business Practice Location Address
First Line	:	2371 N FOREST RD APT 310
Second Line	:
City	:	AMHERST
State	:	NY
Zip	:	14068-1067
Country	:	US
Telephone Number	:	716-563-1179
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/01/2020
Last Update Date	:	12/01/2020

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