Provider Demographics
NPI:1609930015
Name:BLANK, MARYELLEN (NP)
Entity type:Individual
Prefix:MS
First Name:MARYELLEN
Middle Name:
Last Name:BLANK
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 1:170 DRIFTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:WEST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11795-5002
Mailing Address - Country:US
Mailing Address - Phone:631-422-7362
Mailing Address - Fax:
Practice Address - Street 1:21 4TH AVE
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-7908
Practice Address - Country:US
Practice Address - Phone:631-665-6707
Practice Address - Fax:631-665-3564
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY400620364SP0809X
NYF400620-01363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult