Provider Demographics
NPI:1205078904
Name:BALAT, AILEEN M
Entity type:Individual
Prefix:MS
First Name:AILEEN
Middle Name:M
Last Name:BALAT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:N/A
Other - Middle Name:N/A
Other - Last Name:N/A
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NURSE PRACTITIONER
Mailing Address - Street 1:250 BEACH 17TH ST.
Mailing Address - Street 2:
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-1312
Mailing Address - Country:US
Mailing Address - Phone:646-629-3984
Mailing Address - Fax:
Practice Address - Street 1:1 PENN PLAZA 8TH FLOOR
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10119-1312
Practice Address - Country:US
Practice Address - Phone:646-629-3984
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-27
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF304347363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1205078904Medicare PIN