Provider Demographics
NPI:1659021715
Name:BLAKELY, FAUZ MIRIAM (NP)
Entity Type:Individual
Prefix:
First Name:FAUZ
Middle Name:MIRIAM
Last Name:BLAKELY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:199 BRAGGS LN
Mailing Address - Street 2:
Mailing Address - City:BARNSTABLE
Mailing Address - State:MA
Mailing Address - Zip Code:02630-1509
Mailing Address - Country:US
Mailing Address - Phone:774-994-0006
Mailing Address - Fax:
Practice Address - Street 1:199 BRAGGS LN
Practice Address - Street 2:
Practice Address - City:BARNSTABLE
Practice Address - State:MA
Practice Address - Zip Code:02630-1509
Practice Address - Country:US
Practice Address - Phone:774-994-0006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-24
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN280537363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health