Provider Demographics
NPI:1538817648
Name:BLUE, VIVIAN BERTINE (LPN)
Entity type:Individual
Prefix:MISS
First Name:VIVIAN
Middle Name:BERTINE
Last Name:BLUE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3455 WILKENS AVE STE LL20
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21229-5203
Mailing Address - Country:US
Mailing Address - Phone:443-836-5573
Mailing Address - Fax:410-644-5609
Practice Address - Street 1:3455 WILKENS AVE STE LL20
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21229-5203
Practice Address - Country:US
Practice Address - Phone:443-836-5573
Practice Address - Fax:410-644-5609
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-17
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLP45532164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty