Provider Demographics
NPI:1275587701
Name:BLAZEK, MARVEL JEAN (ARNP)
Entity Type:Individual
Prefix:
First Name:MARVEL
Middle Name:JEAN
Last Name:BLAZEK
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 1:609 SE KENT ST
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:IA
Mailing Address - Zip Code:50849-9454
Mailing Address - Country:US
Mailing Address - Phone:641-743-2123
Mailing Address - Fax:641-743-7292
Practice Address - Street 1:609 SE KENT ST
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:IA
Practice Address - Zip Code:50849-9454
Practice Address - Country:US
Practice Address - Phone:641-743-6189
Practice Address - Fax:641-743-6217
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2013-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA047506363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA32933OtherBLUE CROSS/BLUE SHIELD
IA3283259Medicaid
IA48099Medicare PIN
IA32933OtherBLUE CROSS/BLUE SHIELD