Provider Demographics
NPI:1902872815
Name:BLAINE, JOY O (NPC)
Entity type:Individual
Prefix:
First Name:JOY
Middle Name:O
Last Name:BLAINE
Suffix:
Gender:F
Credentials:NPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2333 WHITEHORSE MERCERVILLE RD
Mailing Address - Street 2:STE 4
Mailing Address - City:MERCERVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08619-1946
Mailing Address - Country:US
Mailing Address - Phone:609-890-9111
Mailing Address - Fax:609-890-6865
Practice Address - Street 1:2333 WHITEHORSE MERCERVILLE RD
Practice Address - Street 2:STE 4
Practice Address - City:MERCERVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08619-1946
Practice Address - Country:US
Practice Address - Phone:609-890-9111
Practice Address - Fax:609-890-6865
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2007-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJQ26728363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0054470Medicaid
Q26728Medicare UPIN
NJ084603P6SMedicare PIN