Provider Demographics
NPI:1063983666
Name:BLANC, NATASHA SHELLYANN (HAIRLOSS SPECIALIST)
Entity type:Individual
Prefix:
First Name:NATASHA
Middle Name:SHELLYANN
Last Name:BLANC
Suffix:
Gender:F
Credentials:HAIRLOSS SPECIALIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 WARWICK ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11207-2713
Mailing Address - Country:US
Mailing Address - Phone:347-623-0120
Mailing Address - Fax:
Practice Address - Street 1:375 ROCKAWAY AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11212-5635
Practice Address - Country:US
Practice Address - Phone:718-342-2088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-09
Last Update Date:2018-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY22NE13796391744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management