Provider Demographics
NPI:1629304142
Name:BLANCHETT, PAMELA ROSE (NP-C)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:ROSE
Last Name:BLANCHETT
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 HOSPITAL PLZ STE 502
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902-3602
Mailing Address - Country:US
Mailing Address - Phone:203-348-7410
Mailing Address - Fax:203-961-8488
Practice Address - Street 1:29 HOSPITAL PLZ STE 502
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902-3602
Practice Address - Country:US
Practice Address - Phone:203-348-7410
Practice Address - Fax:203-961-8488
Is Sole Proprietor?:No
Enumeration Date:2009-10-19
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5255363LA2200X, 363LA2200X
MI4704253297363LA2200X
IL209-012821363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
F400219889OtherMEDICARE PTAN
TXAP134739OtherNURSE PRACTITIONER #