Provider Demographics
NPI:1487121240
Name:BLENNER, STEPHANIE GLORIA (PA-C)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:GLORIA
Last Name:BLENNER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 SUNRISE HWY
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE CENTRE
Mailing Address - State:NY
Mailing Address - Zip Code:11570-5100
Mailing Address - Country:US
Mailing Address - Phone:516-678-0500
Mailing Address - Fax:
Practice Address - Street 1:1010 SUNRISE HWY
Practice Address - Street 2:
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-5100
Practice Address - Country:US
Practice Address - Phone:516-678-0500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-30
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant