Provider Demographics
NPI:1538100490
Name:BLATT, LESLIE R (APRN)
Entity Type:Individual
Prefix:MS
First Name:LESLIE
Middle Name:R
Last Name:BLATT
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 BAILEY DR
Mailing Address - Street 2:
Mailing Address - City:NORTH BRANFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06471-1441
Mailing Address - Country:US
Mailing Address - Phone:203-483-5149
Mailing Address - Fax:203-483-5149
Practice Address - Street 1:20 YORK ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-4405
Practice Address - Country:US
Practice Address - Phone:203-688-9277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2009-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001751364SP0809X, 364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
No364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTPO5187Medicare UPIN
CT89000025Medicare ID - Type Unspecified