Provider Demographics
NPI:1639782469
Name:WHITLEY, BLAIR M (NP)
Entity Type:Individual
Prefix:MRS
First Name:BLAIR
Middle Name:M
Last Name:WHITLEY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 ERLAND RD
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-1114
Mailing Address - Country:US
Mailing Address - Phone:631-806-1358
Mailing Address - Fax:
Practice Address - Street 1:300 COMMUNITY DR
Practice Address - Street 2:
Practice Address - City:MANHASSET
Practice Address - State:NY
Practice Address - Zip Code:11030-3816
Practice Address - Country:US
Practice Address - Phone:516-562-0100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-31
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF346085-01363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily