Provider Demographics
NPI:1245729573
Name:BLANCO, CALLIE LYNN (APRN)
Entity type:Individual
Prefix:
First Name:CALLIE
Middle Name:LYNN
Last Name:BLANCO
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:14100 FIVAY RD STE 110
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:FL
Mailing Address - Zip Code:34667-7159
Mailing Address - Country:US
Mailing Address - Phone:727-849-8771
Mailing Address - Fax:727-842-4962
Practice Address - Street 1:6633 FOREST AVE STE 203
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34653-2612
Practice Address - Country:US
Practice Address - Phone:727-849-8771
Practice Address - Fax:727-842-4962
Is Sole Proprietor?:No
Enumeration Date:2018-05-02
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLARNP9334731363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL112062400Medicaid