1659913606 NPI number — SHIRLEY BLANCO NP-C

Table of content: SHIRLEY BLANCO NP-C (NPI 1659913606)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659913606 NPI number — SHIRLEY BLANCO NP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLANCO
Provider First Name:
SHIRLEY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1659913606
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/23/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 95590
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH JORDAN
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84095-0590
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8880 NAVARRE PKWY STE 206
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NAVARRE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32566-3614
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
448-227-5360
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/10/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  11004391 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 104516700 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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