1235192014 NPI number — MARY BLANKEN CRNP

Table of content: MARY BLANKEN CRNP (NPI 1235192014)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235192014 NPI number — MARY BLANKEN CRNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLANKEN
Provider First Name:
MARY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNP
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:
1235192014
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/01/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11800 TECH RD
Provider Second Line Business Mailing Address:
SUITE 240
Provider Business Mailing Address City Name:
SILVER SPRING
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20904-1987
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-754-7740
Provider Business Mailing Address Fax Number:
301-754-7743

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11800 TECH RD
Provider Second Line Business Practice Location Address:
SUITE 240
Provider Business Practice Location Address City Name:
SILVER SPRING
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20904-1987
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-754-7740
Provider Business Practice Location Address Fax Number:
301-754-7743
Provider Enumeration Date:
04/11/2006

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: 363LA2200X , with the licence number:  R098788 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: R098788 . This is a "LICENSE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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