Provider Demographics
NPI:1639821598
Name:BLAIZE, ROBIN MADONNA
Entity Type:Individual
Prefix:
First Name:ROBIN
Middle Name:MADONNA
Last Name:BLAIZE
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 1:518 BEACH 32ND ST
Mailing Address - Street 2:
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-1933
Mailing Address - Country:US
Mailing Address - Phone:347-933-8383
Mailing Address - Fax:
Practice Address - Street 1:3425 VERNON BLVD
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11106-5121
Practice Address - Country:US
Practice Address - Phone:844-815-1508
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-21
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY755337163WP0809X
NYF404761363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult