Provider Demographics
NPI:1639880610
Name:DALEY, BLONDELL MIRANDA
Entity Type:Individual
Prefix:
First Name:BLONDELL
Middle Name:MIRANDA
Last Name:DALEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8007 15TH AVE APT 8007
Mailing Address - Street 2:
Mailing Address - City:ADELPHI
Mailing Address - State:MD
Mailing Address - Zip Code:20783-4804
Mailing Address - Country:US
Mailing Address - Phone:240-204-0518
Mailing Address - Fax:
Practice Address - Street 1:8007 15TH AVE APT 8007
Practice Address - Street 2:
Practice Address - City:ADELPHI
Practice Address - State:MD
Practice Address - Zip Code:20783-4804
Practice Address - Country:US
Practice Address - Phone:240-204-0518
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-09
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA19004382225700000X
MDM05441225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist