Healthcare Provider Details

I. General information

NPI: 1639425457
Provider Name (Legal Business Name): MS. KEYANNA MARIE BLAND
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2012
Last Update Date: 07/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39155 LIBERTY ST SUITE E500
FREMONT CA
94538-1513
US

IV. Provider business mailing address

4802 CASTILLA AVE
RICHMOND CA
94804-4336
US

V. Phone/Fax

Practice location:
  • Phone: 510-574-2114
  • Fax:
Mailing address:
  • Phone: 510-621-4744
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: