Provider Demographics
NPI:1669723144
Name:BLANCO, MAELA
Entity type:Individual
Prefix:
First Name:MAELA
Middle Name:
Last Name:BLANCO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5145 ALMEDA AVE
Mailing Address - Street 2:2D
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-1016
Mailing Address - Country:US
Mailing Address - Phone:646-207-9317
Mailing Address - Fax:
Practice Address - Street 1:5145 ALMEDA AVE
Practice Address - Street 2:2D
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NV
Practice Address - Zip Code:11691
Practice Address - Country:US
Practice Address - Phone:646-207-9317
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-25
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY543177111174400000X
NY496221111174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist