Provider Demographics
NPI:1568252161
Name:GILBERT BLANCHARD, ALTAGRACE
Entity type:Individual
Prefix:
First Name:ALTAGRACE
Middle Name:
Last Name:GILBERT BLANCHARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 ELK ST
Mailing Address - Street 2:
Mailing Address - City:WYANDANCH
Mailing Address - State:NY
Mailing Address - Zip Code:11798-3309
Mailing Address - Country:US
Mailing Address - Phone:631-303-4558
Mailing Address - Fax:
Practice Address - Street 1:153 LAKE SHORE RD
Practice Address - Street 2:
Practice Address - City:LAKE RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-3157
Practice Address - Country:US
Practice Address - Phone:844-815-1508
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-08
Last Update Date:2025-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY33454001164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse