Basic Information
| Provider Information | |||||||||
| NPI: | 1790271385 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLANKS | ||||||||
| FirstName: | GERZALLE | ||||||||
| MiddleName: | A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 992 WINDSOR ST | ||||||||
| Address2: | |||||||||
| City: | LA PLACE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 700685246 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1836 SAINT BERNARD AVE STE B | ||||||||
| Address2: | |||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701161329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5046032389 | ||||||||
| FaxNumber: | 5046093366 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2018 | ||||||||
| LastUpdateDate: | 07/06/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 008839330 | 01 | LA | DRIVER'S LICENSE | OTHER |