MEDICARE: MRS. ABIGAIL JEN BLANK MS

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	174400000X	Specialist	2390556	NY

General Provider Information

NPI Number	:	1619230604
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ABIGAIL JEN BLANK MS

Provider Business Mailing Address
First Line	:	366 NEW YORK AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11213-4228
Country	:	US
Telephone Number	:	718-363-9313
Fax Number	:

Provider Business Practice Location Address
First Line	:	366 NEW YORK AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11213-4228
Country	:	US
Telephone Number	:	718-363-9313
Fax Number	:

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

Provider Enumeration Date	:	06/24/2012
Last Update Date	:	06/24/2012

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