Provider Demographics
NPI:1528622701
Name:POMEROY-BRAWNER, BLAIZE MORNINGSTAR (LMT)
Entity type:Individual
Prefix:
First Name:BLAIZE
Middle Name:MORNINGSTAR
Last Name:POMEROY-BRAWNER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12-128 MAPUANA AVE
Mailing Address - Street 2:
Mailing Address - City:PAHOA
Mailing Address - State:HI
Mailing Address - Zip Code:96778-7833
Mailing Address - Country:US
Mailing Address - Phone:808-965-7422
Mailing Address - Fax:
Practice Address - Street 1:12-128 MAPUANA AVE
Practice Address - Street 2:
Practice Address - City:PAHOA
Practice Address - State:HI
Practice Address - Zip Code:96778-7833
Practice Address - Country:US
Practice Address - Phone:808-965-7422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-23
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI14870225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist