Most Relevant Information
Provider Data
| NPI Number: | 1003445842 |
| Provider Name: | BLAZE KELLY |
| Entity Type: | Individual |
| Taxonomy Code: | 390200000X |
| Specialty: | Student in an Organized Health Care Education/Training Program |
| License Number: | OT019937 |
Most Important Dates
| Enumeration Date: | 04/03/2020 |
| Last Updated: | 04/30/2020 |
Provider Practice Location
111 S 11TH ST STE 8290
PHILADELPHIA
PA
191074824
Practice Location Phone/Fax
| Phone: | 2159552370 |
| Fax: | 2159550677 |
Provider Mailing Location
111 S 11TH ST STE 8290
PHILADELPHIA
PA
191074824
Provider Mailing Phone/Fax
| Phone: | 2159552370 |
| Fax: | 2159550677 |