Healthcare Provider Details

I. General information

NPI: 1669789673
Provider Name (Legal Business Name): MISTI DIANEE BALZER C.P.M
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2010
Last Update Date: 09/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

218 N WHITNEY ST
SAINT AUGUSTINE FL
32084-0441
US

IV. Provider business mailing address

218 N WHITNEY ST
SAINT AUGUSTINE FL
32084-0441
US

V. Phone/Fax

Practice location:
  • Phone: 904-806-6240
  • Fax:
Mailing address:
  • Phone: 904-806-6240
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: