Provider Demographics
NPI:1619230604
Name:BLANK, ABIGAIL JEN (MS)
Entity Type:Individual
Prefix:MRS
First Name:ABIGAIL
Middle Name:JEN
Last Name:BLANK
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:366 NEW YORK AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11213-4228
Mailing Address - Country:US
Mailing Address - Phone:718-363-9313
Mailing Address - Fax:
Practice Address - Street 1:366 NEW YORK AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11213-4228
Practice Address - Country:US
Practice Address - Phone:718-363-9313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-24
Last Update Date:2012-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2390556174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist