Provider Demographics
NPI:1104486471
Name:BLAZE, TANISHA SHAREE
Entity type:Individual
Prefix:
First Name:TANISHA
Middle Name:SHAREE
Last Name:BLAZE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23341 HEMLOCK AVE APT 13
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92557-7003
Mailing Address - Country:US
Mailing Address - Phone:951-419-2317
Mailing Address - Fax:
Practice Address - Street 1:14677 MERRILL AVE
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335
Practice Address - Country:US
Practice Address - Phone:951-643-2340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-18
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist