Provider Demographics
NPI:1720642234
Name:BLIZARD, AMANDA MARIA
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARIA
Last Name:BLIZARD
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 1:4 SPRING LAKE CT
Mailing Address - Street 2:
Mailing Address - City:SEWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:08080-2103
Mailing Address - Country:US
Mailing Address - Phone:856-582-3768
Mailing Address - Fax:
Practice Address - Street 1:3401 CIVIC CENTER BLVD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4319
Practice Address - Country:US
Practice Address - Phone:215-590-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-30
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA699773163W00000X
DELJ0000359363LP0200X
NJ26NJ00921400363LP0200X
PASP020379363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics