Provider Demographics
NPI:1841939105
Name:BLACKMORE, DANIELLE NICOLE (NP)
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:NICOLE
Last Name:BLACKMORE
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 1:64 PENNY DR
Mailing Address - Street 2:
Mailing Address - City:CALVERTON
Mailing Address - State:NY
Mailing Address - Zip Code:11933-1130
Mailing Address - Country:US
Mailing Address - Phone:516-768-5174
Mailing Address - Fax:
Practice Address - Street 1:101 NICOLLS RD
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-0001
Practice Address - Country:US
Practice Address - Phone:631-444-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-03
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY634244163WN0002X
NY350560363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
No163WN0002XNursing Service ProvidersRegistered NurseNeonatal Intensive Care