Provider Demographics
NPI:1205185055
Name:BLAKELY, JUDITH ELISA (APRN: PSYCHIATRY)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:ELISA
Last Name:BLAKELY
Suffix:
Gender:F
Credentials:APRN: PSYCHIATRY
Other - Prefix:
Other - First Name:JUDITH
Other - Middle Name:
Other - Last Name:YOUNG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:375 BAY RD
Mailing Address - Street 2:
Mailing Address - City:QUEENSBURY
Mailing Address - State:NY
Mailing Address - Zip Code:12804-3012
Mailing Address - Country:US
Mailing Address - Phone:518-480-7870
Mailing Address - Fax:
Practice Address - Street 1:375 BAY RD
Practice Address - Street 2:
Practice Address - City:QUEENSBURY
Practice Address - State:NY
Practice Address - Zip Code:12804-3012
Practice Address - Country:US
Practice Address - Phone:518-480-7870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-06
Last Update Date:2022-12-07
Deactivation Date:2019-01-14
Deactivation Code:
Reactivation Date:2020-04-13
Provider Licenses
StateLicense IDTaxonomies
VT026.0015348363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health