Provider Demographics
NPI:1992167068
Name:BLAZEK, ALICE (RN)
Entity type:Individual
Prefix:
First Name:ALICE
Middle Name:
Last Name:BLAZEK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 17
Mailing Address - Street 2:
Mailing Address - City:CHATFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:75105-0017
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4830 FM 1603
Practice Address - Street 2:
Practice Address - City:CHATFIELD
Practice Address - State:TX
Practice Address - Zip Code:75105-0017
Practice Address - Country:US
Practice Address - Phone:903-654-8199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-28
Last Update Date:2016-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula