Healthcare Provider Details

I. General information

NPI: 1013664655
Provider Name (Legal Business Name): KARLIE ANNE BLAZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2022
Last Update Date: 03/03/2022
Certification Date: 03/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2323 TEXAS ST
PECOS TX
79772-7338
US

IV. Provider business mailing address

2323 TEXAS ST
PECOS TX
79772-7338
US

V. Phone/Fax

Practice location:
  • Phone: 432-447-3551
  • Fax:
Mailing address:
  • Phone: 815-354-4819
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number160009515
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: