Provider Demographics
NPI:1023838836
Name:BLAKE-BRAMWELL, COLLEEN SHANNA LEE
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:SHANNA LEE
Last Name:BLAKE-BRAMWELL
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 1:7091 ENVIRON BLVD APT 247
Mailing Address - Street 2:
Mailing Address - City:LAUDERHILL
Mailing Address - State:FL
Mailing Address - Zip Code:33319-4211
Mailing Address - Country:US
Mailing Address - Phone:754-946-0063
Mailing Address - Fax:
Practice Address - Street 1:3300 S UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33328-2004
Practice Address - Country:US
Practice Address - Phone:954-262-4550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-15
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPSI46729390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program