Basic Information
| Provider Information | |||||||||
| NPI: | 1215295100 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLOUNT-DARTY | ||||||||
| FirstName: | MEDINA | ||||||||
| MiddleName: | T | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | R.N. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BLOUNT | ||||||||
| OtherFirstName: | MEDINA | ||||||||
| OtherMiddleName: | T. | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | R.N. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 406 LONGELLOW AVE | ||||||||
| Address2: | |||||||||
| City: | WYNCOTE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19095 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2158852637 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1930 S BROAD ST | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191452328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2153394563 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2012 | ||||||||
| LastUpdateDate: | 04/27/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN313030L | PA | Y | Nursing Service Providers | Registered Nurse |
No ID Information.