Provider Demographics
NPI:1700655651
Name:BLUE ZONE LEGACY INC
Entity Type:Organization
Organization Name:BLUE ZONE LEGACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAPHNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:SYDNEY
Authorized Official - Suffix:
Authorized Official - Credentials:DNP
Authorized Official - Phone:954-832-2651
Mailing Address - Street 1:404 NW 68TH AVE APT 406
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33317-7596
Mailing Address - Country:US
Mailing Address - Phone:954-832-2651
Mailing Address - Fax:
Practice Address - Street 1:404 NW 68TH AVE APT 406
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33317-7596
Practice Address - Country:US
Practice Address - Phone:954-832-2651
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-20
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty