Individual
MS. MARYELLEN BLANK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
NP
Contact information
Practice address
21 4TH AVE, BAY SHORE, NY 11706-7908
(631) 665-6707
(631) 665-3564
Mailing address
170 DRIFTWOOD DR, WEST ISLIP, NY 11795-5002
(631) 422-7362
Taxonomy
Speciality
Code
Description
License number
State
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
Primary
F400620-01
NY
364SP0809X
Adult Psychiatric/Mental Health Clinical Nurse Specialist
400620
NY
Other
Enumeration date
12/20/2006
Last updated
10/17/2024
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