Provider Demographics
NPI:1295346542
Name:BLOUNT, JOHANNE (NP)
Entity type:Individual
Prefix:MRS
First Name:JOHANNE
Middle Name:
Last Name:BLOUNT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13464 173RD ST FL 1
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11434-4538
Mailing Address - Country:US
Mailing Address - Phone:718-749-1061
Mailing Address - Fax:
Practice Address - Street 1:760 BROADWAY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11206-5383
Practice Address - Country:US
Practice Address - Phone:718-963-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-11
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY309839363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health