Basic Information
Provider Information | |||||||||
NPI: | 1629717384 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BLANC | ||||||||
FirstName: | SAMANTHA | ||||||||
MiddleName: | NICOLE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 207 N CHASE ST | ||||||||
Address2: |   | ||||||||
City: | JOHNSTOWN | ||||||||
State: | NY | ||||||||
PostalCode: | 120951810 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5183326466 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 5344 SACANDAGA RD | ||||||||
Address2: |   | ||||||||
City: | GALWAY | ||||||||
State: | NY | ||||||||
PostalCode: | 120742422 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5188826955 | ||||||||
FaxNumber: | 5188865880 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/01/2022 | ||||||||
LastUpdateDate: | 06/30/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/30/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | F349703 | NY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.