Provider Demographics
NPI:1407223696
Name:BLAZEK, PAMELA (ND LMT)
Entity Type:Individual
Prefix:MS
First Name:PAMELA
Middle Name:
Last Name:BLAZEK
Suffix:
Gender:F
Credentials:ND LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1919 ASSUMPTION DR
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-1506
Mailing Address - Country:US
Mailing Address - Phone:701-390-2169
Mailing Address - Fax:
Practice Address - Street 1:3123 N 14TH ST
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503-1330
Practice Address - Country:US
Practice Address - Phone:701-390-2169
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-24
Last Update Date:2015-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND312225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist