1003155078 NPI number — MS. CANDACE ANNE BLASE LCPAT

Table of content: MS. CANDACE ANNE BLASE LCPAT (NPI 1003155078)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003155078 NPI number — MS. CANDACE ANNE BLASE LCPAT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLASE
Provider First Name:
CANDACE
Provider Middle Name:
ANNE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LCPAT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003155078
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/11/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14601 ROXBURY RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GLENELG
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21737-9611
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
443-280-0677
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5560 STERRETT PL
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21044-2601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
443-546-4000
Provider Business Practice Location Address Fax Number:
443-546-4005
Provider Enumeration Date:
02/11/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X , with the licence number:  ATC003 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com