Provider Demographics
NPI:1124449459
Name:POLLACK, BLYTHE (CPNP-AC)
Entity type:Individual
Prefix:MRS
First Name:BLYTHE
Middle Name:
Last Name:POLLACK
Suffix:
Gender:F
Credentials:CPNP-AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3621 SOUTH STATE STREET
Mailing Address - Street 2:700 KMS PLACE
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108
Mailing Address - Country:US
Mailing Address - Phone:734-936-2047
Mailing Address - Fax:
Practice Address - Street 1:1500 E MEDICAL CENTER DR
Practice Address - Street 2:10TH FLOOR C.S. MOTT CHILDREN'S HOSPITAL
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48109-4286
Practice Address - Country:US
Practice Address - Phone:734-763-5302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-06
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704266977363LP0222X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0222XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics, Critical Care