Provider Demographics
NPI:1801371786
Name:BLACKBURNE, PETER JOEL (RN)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:JOEL
Last Name:BLACKBURNE
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11580-2925
Mailing Address - Country:US
Mailing Address - Phone:718-775-1200
Mailing Address - Fax:
Practice Address - Street 1:3 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11580-2925
Practice Address - Country:US
Practice Address - Phone:718-775-1200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-26
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY535252163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health