Provider Demographics
NPI:1215295100
Name:BLOUNT-DARTY, MEDINA T (RN)
Entity type:Individual
Prefix:MRS
First Name:MEDINA
Middle Name:T
Last Name:BLOUNT-DARTY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MRS
Other - First Name:MEDINA
Other - Middle Name:T
Other - Last Name:BLOUNT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:406 LONGELLOW AVE
Mailing Address - Street 2:
Mailing Address - City:WYNCOTE
Mailing Address - State:PA
Mailing Address - Zip Code:19095
Mailing Address - Country:US
Mailing Address - Phone:215-885-2637
Mailing Address - Fax:
Practice Address - Street 1:1930 S BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19145-2328
Practice Address - Country:US
Practice Address - Phone:215-339-4563
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-27
Last Update Date:2012-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN313030L163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse