Provider Demographics
NPI:1538665161
Name:BLAZEK, ELIZABETH R (RN)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:R
Last Name:BLAZEK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2797
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68103-2797
Mailing Address - Country:US
Mailing Address - Phone:402-354-4230
Mailing Address - Fax:402-354-6171
Practice Address - Street 1:8303 DODGE ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114
Practice Address - Country:US
Practice Address - Phone:402-354-2917
Practice Address - Fax:402-354-3160
Is Sole Proprietor?:No
Enumeration Date:2018-04-03
Last Update Date:2018-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE79761163W00000X
NE112494363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47037660432Medicaid
IA1538665161Medicaid