Provider Demographics
NPI:1386246692
Name:FAHNESTOCK, BLAZE (FNP)
Entity type:Individual
Prefix:
First Name:BLAZE
Middle Name:
Last Name:FAHNESTOCK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:BLAZE
Other - Middle Name:
Other - Last Name:KRAVEC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:61 DELANO ST
Mailing Address - Street 2:
Mailing Address - City:PULASKI
Mailing Address - State:NY
Mailing Address - Zip Code:13142-1400
Mailing Address - Country:US
Mailing Address - Phone:315-298-6569
Mailing Address - Fax:
Practice Address - Street 1:61 DELANO ST
Practice Address - Street 2:
Practice Address - City:PULASKI
Practice Address - State:NY
Practice Address - Zip Code:13142-1400
Practice Address - Country:US
Practice Address - Phone:315-298-6569
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-11
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY346711363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner