Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LW0102X | Nurse Practitioner - Women's Health | F420760 | NY |
NPI | 1033193768 |
---|---|
Provider Name | Ms. Jessica Blue |
First Address | New York, NY 10012-2413 |
Second Address | New York, NY 10012-2413 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/12/2005 |
Last Update Date | 17/01/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
02766681 | (05) | NY |