Provider Demographics
NPI:1972587582
Name:BLANKSON, MARY L (APRN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:L
Last Name:BLANKSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:E
Other - Last Name:LAPLANTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:575 MAIN ST FL 2
Mailing Address - Street 2:ATTN: CREDENTIALING DEPARTMENT
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-2845
Mailing Address - Country:US
Mailing Address - Phone:860-347-6971
Mailing Address - Fax:860-638-6601
Practice Address - Street 1:1 SHAWS CV
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-4902
Practice Address - Country:US
Practice Address - Phone:860-447-8304
Practice Address - Fax:860-443-8720
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2013-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003321363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008011052Medicaid
Q59219Medicare UPIN
CT500001616Medicare PIN