Provider Demographics
NPI:1659243285
Name:BLANK-WILKES, CARRIE
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:
Last Name:BLANK-WILKES
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 1:62 ANNANDALE RD
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-1746
Mailing Address - Country:US
Mailing Address - Phone:631-398-6582
Mailing Address - Fax:
Practice Address - Street 1:62 ANNANDALE RD
Practice Address - Street 2:
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-1746
Practice Address - Country:US
Practice Address - Phone:631-398-6582
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-23
Last Update Date:2025-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist