Basic Information
| Provider Information | |||||||||
| NPI: | 1366964447 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLAZKIEWICZ | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | MICHELLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 154 TABB AVE | ||||||||
| Address2: | |||||||||
| City: | PISCATAWAY | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088542570 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1200 W TABOR RD | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191413019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154569850 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2017 | ||||||||
| LastUpdateDate: | 07/13/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 06/10/2022 | ||||||||
| NPIReactivationDate: | 07/13/2022 | ||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | N | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.