Provider Demographics
NPI:1679893655
Name:BLAJSZCZAK, MIRANDA ELIZABETH (RN)
Entity Type:Individual
Prefix:MRS
First Name:MIRANDA
Middle Name:ELIZABETH
Last Name:BLAJSZCZAK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2340 S COFFMAN AVE
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82604-3521
Mailing Address - Country:US
Mailing Address - Phone:307-265-6698
Mailing Address - Fax:
Practice Address - Street 1:2340 S COFFMAN AVE
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82604-3521
Practice Address - Country:US
Practice Address - Phone:307-265-6698
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-01
Last Update Date:2011-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY22824163WP0808X
251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health