Provider Demographics
NPI:1083739502
Name:PATRICK-BLAIKIE, JEANNINE (CRNP)
Entity type:Individual
Prefix:
First Name:JEANNINE
Middle Name:
Last Name:PATRICK-BLAIKIE
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 E BROWN ST
Mailing Address - Street 2:
Mailing Address - City:EAST STROUDSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18301-3006
Mailing Address - Country:US
Mailing Address - Phone:570-420-4951
Mailing Address - Fax:570-476-3754
Practice Address - Street 1:292 FRANTZ RD
Practice Address - Street 2:STE 108
Practice Address - City:STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18360-7455
Practice Address - Country:US
Practice Address - Phone:570-426-2960
Practice Address - Fax:570-426-2965
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAVP006532C363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAVP006532COtherPA STATE LICENSE
PAVP006532COtherPA STATE LICENSE