Basic Information
| Provider Information | |||||||||
| NPI: | 1619620234 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLADE | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | NAKANO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 802 BREWSTER AVE | ||||||||
| Address2: | |||||||||
| City: | REDWOOD CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940631510 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 802 BREWSTER AVE | ||||||||
| Address2: | |||||||||
| City: | REDWOOD CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940631510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6503634111 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2022 | ||||||||
| LastUpdateDate: | 02/17/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 175T00000X | N | 172V00000X | Y | Other Service Providers | Community Health Worker |
No ID Information.