Provider Demographics
NPI:1659642064
Name:BLANC, KERLYNE (MSED)
Entity Type:Individual
Prefix:MRS
First Name:KERLYNE
Middle Name:
Last Name:BLANC
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:KERLYNE
Other - Middle Name:
Other - Last Name:MATHIEU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSED
Mailing Address - Street 1:24416 136TH RD
Mailing Address - Street 2:
Mailing Address - City:ROSEDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11422-1623
Mailing Address - Country:US
Mailing Address - Phone:347-858-7951
Mailing Address - Fax:
Practice Address - Street 1:60 MADISON AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-1600
Practice Address - Country:US
Practice Address - Phone:212-684-0099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-17
Last Update Date:2012-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY553952111174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist