Basic Information
| Provider Information | |||||||||
| NPI: | 1669962304 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLATKIEWICZ | ||||||||
| FirstName: | PAMELA | ||||||||
| MiddleName: | ROSE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15000 MIDLANTIC DR STE 102 | ||||||||
| Address2: | |||||||||
| City: | MOUNT LAUREL | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080541573 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 15000 MIDLANTIC DR STE 102 | ||||||||
| Address2: | |||||||||
| City: | MOUNT LAUREL | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080541573 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8557272465 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2018 | ||||||||
| LastUpdateDate: | 10/30/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 26NR18788300 | NJ | N | Nursing Service Providers | Registered Nurse | 163W00000X | RN689771 | PA | N | Nursing Service Providers | Registered Nurse | 363LF0000X | SP018879 | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 26NJ00817900 | NJ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.