Provider Demographics
NPI:1104605625
Name:BLANCO, MIRTHA LIDIA (APRN)
Entity type:Individual
Prefix:MS
First Name:MIRTHA
Middle Name:LIDIA
Last Name:BLANCO
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 EAGLES NEST DR
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:FL
Mailing Address - Zip Code:32439-2398
Mailing Address - Country:US
Mailing Address - Phone:808-393-8510
Mailing Address - Fax:
Practice Address - Street 1:20 EAGLES NEST DR
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:FL
Practice Address - Zip Code:32439-2398
Practice Address - Country:US
Practice Address - Phone:808-393-8510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-25
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11028794363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily