Healthcare Provider Details

I. General information

NPI: 1932862778
Provider Name (Legal Business Name): BLAIZE XZAVIAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2021
Last Update Date: 10/19/2021
Certification Date: 10/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4910 CREEKSIDE DR STE D
CLEARWATER FL
33760-4034
US

IV. Provider business mailing address

24808 PERMIT WAY
LAND O LAKES FL
34639-6323
US

V. Phone/Fax

Practice location:
  • Phone: 727-593-0003
  • Fax:
Mailing address:
  • Phone: 808-561-8234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number252003
License Number StateFM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: