Provider Demographics
NPI:1033687629
Name:BLANKENBERG, CRISSA CAROLYN (LPN)
Entity Type:Individual
Prefix:
First Name:CRISSA
Middle Name:CAROLYN
Last Name:BLANKENBERG
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 ARROWHEAD DR
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14624-2804
Mailing Address - Country:US
Mailing Address - Phone:585-730-0693
Mailing Address - Fax:
Practice Address - Street 1:107 N CLINTON AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14604-1411
Practice Address - Country:US
Practice Address - Phone:585-324-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-13
Last Update Date:2018-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY315182164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse