Provider Demographics
NPI:1104851617
Name:BLANDFORD, ALICE MARIE (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:ALICE
Middle Name:MARIE
Last Name:BLANDFORD
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 W AZTEC AVE
Mailing Address - Street 2:
Mailing Address - City:CLEWISTON
Mailing Address - State:FL
Mailing Address - Zip Code:33440-4401
Mailing Address - Country:US
Mailing Address - Phone:863-983-3434
Mailing Address - Fax:863-983-6655
Practice Address - Street 1:500 W SAGAMORE AVE
Practice Address - Street 2:
Practice Address - City:CLEWISTON
Practice Address - State:FL
Practice Address - Zip Code:33440-3514
Practice Address - Country:US
Practice Address - Phone:863-983-3434
Practice Address - Fax:863-983-6655
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1142282363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL305863800Medicaid
FL305863800Medicaid
FLP86751Medicare UPIN