Provider Demographics
NPI:1194166223
Name:PALAGONIA, BLAKE
Entity type:Individual
Prefix:MRS
First Name:BLAKE
Middle Name:
Last Name:PALAGONIA
Suffix:
Gender:F
Credentials:
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 424
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11768-0424
Mailing Address - Country:US
Mailing Address - Phone:516-361-4290
Mailing Address - Fax:
Practice Address - Street 1:3019 TIMOTHY RD
Practice Address - Street 2:
Practice Address - City:BELLMORE
Practice Address - State:NY
Practice Address - Zip Code:11710-5225
Practice Address - Country:US
Practice Address - Phone:516-361-4290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-17
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY732094131174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist