Provider Demographics
NPI:1568265221
Name:PHARAOH MIND
Entity type:Organization
Organization Name:PHARAOH MIND
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHIATRIC NP
Authorized Official - Prefix:
Authorized Official - First Name:DARRELL
Authorized Official - Middle Name:
Authorized Official - Last Name:YOUNGBLOOD
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC
Authorized Official - Phone:504-544-1061
Mailing Address - Street 1:750 W DIMOND BLVD STE 103NO239
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99515-1515
Mailing Address - Country:US
Mailing Address - Phone:504-544-1061
Mailing Address - Fax:
Practice Address - Street 1:165 N VILLAGE AVE STE 12
Practice Address - Street 2:
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-3701
Practice Address - Country:US
Practice Address - Phone:504-544-1061
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-28
Last Update Date:2025-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY406045OtherNURSE PRACTITIONER-PSYCHIATRY