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NPI Code Detail

MEDICARE: MS. MARYELLEN BLANK NP

MEDICARE: MS. MARYELLEN BLANK NP
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
1364SP0809XAdult Psychiatric/Mental Health Clinical Nurse Specialist400620NY
2363LP0808XPsychiatric/Mental Health Nurse PractitionerF400620-01NY

General Provider Information

NPI Number : 1609930015
Entity Type Code : Individual
Provider Name (Legal Business Name) : MS. MARYELLEN BLANK NP
Provider Business Mailing Address
First Line : 170 DRIFTWOOD DR
Second Line :
City : WEST ISLIP
State : NY
Zip : 11795-5002
Country : US
Telephone Number : 631-422-7362
Fax Number :
Provider Business Practice Location Address
First Line : 21 4TH AVE
Second Line :
City : BAY SHORE
State : NY
Zip : 11706-7908
Country : US
Telephone Number : 631-665-6707
Fax Number : 631-665-3564
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/20/2006
Last Update Date : 10/17/2024

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