Provider Demographics
NPI:1104817501
Name:BLECKLEY, ELAINE M (NP)
Entity type:Individual
Prefix:MS
First Name:ELAINE
Middle Name:M
Last Name:BLECKLEY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 68
Mailing Address - Street 2:
Mailing Address - City:S WEYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02190-0001
Mailing Address - Country:US
Mailing Address - Phone:780-803-2786
Mailing Address - Fax:781-812-1631
Practice Address - Street 1:223 CHIEF JUSTICE CUSHING HWY
Practice Address - Street 2:STE 101
Practice Address - City:COHASSET
Practice Address - State:MA
Practice Address - Zip Code:02025-1391
Practice Address - Country:US
Practice Address - Phone:781-383-6800
Practice Address - Fax:781-383-6504
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA189296363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0347230Medicaid
MANP9824OtherBCBS
MANP4942Medicare ID - Type Unspecified
MANP9824OtherBCBS
Q37654Medicare UPIN