Provider Demographics
NPI:1962495382
Name:BLANK, BETSY (CRNP)
Entity Type:Individual
Prefix:
First Name:BETSY
Middle Name:
Last Name:BLANK
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 465
Mailing Address - Street 2:
Mailing Address - City:LOTHIAN
Mailing Address - State:MD
Mailing Address - Zip Code:20711-0465
Mailing Address - Country:US
Mailing Address - Phone:301-751-3888
Mailing Address - Fax:301-262-7383
Practice Address - Street 1:1737 CARRY PL
Practice Address - Street 2:
Practice Address - City:CROFTON
Practice Address - State:MD
Practice Address - Zip Code:21114-2324
Practice Address - Country:US
Practice Address - Phone:301-751-3888
Practice Address - Fax:301-262-7383
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-31
Last Update Date:2010-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR097929363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC53590002OtherCAREFIRST BCBS GHMS
MD687602100Medicaid
DC53590002OtherCAREFIRST BCBS GHMS
MD492101Medicare PIN