Basic Information
| Provider Information | |||||||||
| NPI: | 1972587582 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLANKSON | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | APRN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LAPLANTE | ||||||||
| OtherFirstName: | MARY | ||||||||
| OtherMiddleName: | E | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | APRN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 575 MAIN ST FL 2 | ||||||||
| Address2: | ATTN: CREDENTIALING DEPARTMENT | ||||||||
| City: | MIDDLETOWN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064572845 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8603476971 | ||||||||
| FaxNumber: | 8606386601 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 SHAWS CV | ||||||||
| Address2: | |||||||||
| City: | NEW LONDON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 063204902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8604478304 | ||||||||
| FaxNumber: | 8604438720 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2005 | ||||||||
| LastUpdateDate: | 11/29/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 003321 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 008011052 | 05 | CT | MEDICAID |