Provider Demographics
NPI:1619585379
Name:BLANCHARD, ANGIE
Entity Type:Individual
Prefix:
First Name:ANGIE
Middle Name:
Last Name:BLANCHARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1608 E 95TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236-5414
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1608 E 95TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11236-5414
Practice Address - Country:US
Practice Address - Phone:929-390-9541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-20
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY33764101164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse