Provider Demographics
NPI:1144929209
Name:BLAISE, REGINE (FPMHNP)
Entity type:Individual
Prefix:MISS
First Name:REGINE
Middle Name:
Last Name:BLAISE
Suffix:
Gender:F
Credentials:FPMHNP
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 1133
Mailing Address - Street 2:
Mailing Address - City:WEST BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11704-0133
Mailing Address - Country:US
Mailing Address - Phone:631-987-4632
Mailing Address - Fax:
Practice Address - Street 1:11835 QUEENS BLVD STE 1630
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-7256
Practice Address - Country:US
Practice Address - Phone:925-231-4325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-27
Last Update Date:2025-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ15040200363LP0808X
NYF404790363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty