Provider Demographics
NPI:1255096707
Name:BLAZE, KELSO LYNNE-BORRELL
Entity type:Individual
Prefix:
First Name:KELSO
Middle Name:LYNNE-BORRELL
Last Name:BLAZE
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 1:2530 N HOWARD ST UNIT 2
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19133
Mailing Address - Country:US
Mailing Address - Phone:732-744-4962
Mailing Address - Fax:
Practice Address - Street 1:2530 N HOWARD ST UNIT 2
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19133
Practice Address - Country:US
Practice Address - Phone:732-744-4962
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-01
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA5306693119Medicaid