Provider Demographics
NPI:1326647470
Name:ISHIMWE, BLAISE (DSP)
Entity Type:Individual
Prefix:MR
First Name:BLAISE
Middle Name:
Last Name:ISHIMWE
Suffix:
Gender:M
Credentials:DSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 COBALT CT # PVT
Mailing Address - Street 2:
Mailing Address - City:WINDHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04062-4691
Mailing Address - Country:US
Mailing Address - Phone:225-284-6850
Mailing Address - Fax:
Practice Address - Street 1:3 COBALT CT # PVT
Practice Address - Street 2:
Practice Address - City:WINDHAM
Practice Address - State:ME
Practice Address - Zip Code:04062-4691
Practice Address - Country:US
Practice Address - Phone:225-284-6850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-20
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker