Healthcare Provider Details

I. General information

NPI: 1174460836
Provider Name (Legal Business Name): KIAJERA OSHANAY BLACKSTON DACCHM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2026
Last Update Date: 04/30/2026
Certification Date: 04/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29675 N NORTH VALLEY PKWY UNIT 2004
PHOENIX AZ
85085-0784
US

IV. Provider business mailing address

29675 N NORTH VALLEY PKWY UNIT 2004
PHOENIX AZ
85085-0784
US

V. Phone/Fax

Practice location:
  • Phone: 562-713-8548
  • Fax:
Mailing address:
  • Phone: 562-713-8548
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number27299
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: