Basic Information
| Provider Information | |||||||||
| NPI: | 1871165852 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLANCO | ||||||||
| FirstName: | VIVIAN | ||||||||
| MiddleName: | SALVADOR | ||||||||
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| Credential: | PMHNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1947 HILLSIDE AVE | ||||||||
| Address2: | |||||||||
| City: | NISKAYUNA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 123094017 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1101 NOTT ST | ||||||||
| Address2: | |||||||||
| City: | SCHENECTADY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 123082425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5182434000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2021 | ||||||||
| LastUpdateDate: | 07/20/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | F403483 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | F403483 | 01 | NY | LICENSE REGISTRATION NUMBER | OTHER |