Provider Demographics
NPI:1578683587
Name:BLOUNT, JULIETTE GRANT (NP)
Entity type:Individual
Prefix:
First Name:JULIETTE
Middle Name:GRANT
Last Name:BLOUNT
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 1:89-56 162ND STREET
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11432-2392
Mailing Address - Country:US
Mailing Address - Phone:718-657-1100
Mailing Address - Fax:
Practice Address - Street 1:89-56 162ND STREET
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432
Practice Address - Country:US
Practice Address - Phone:347-505-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-31
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY424450163W00000X
NYF303578363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02396174Medicaid
NY02396174Medicaid
NY0363G1Medicare ID - Type Unspecified