Provider Demographics
NPI:1740925601
Name:FELICIEN, BLOSSOM MANDY (MA)
Entity type:Individual
Prefix:
First Name:BLOSSOM
Middle Name:MANDY
Last Name:FELICIEN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2323 S 109TH ST STE 130B
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53227-1909
Mailing Address - Country:US
Mailing Address - Phone:414-334-5224
Mailing Address - Fax:
Practice Address - Street 1:2323 S 109TH ST STE 130B
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-1909
Practice Address - Country:US
Practice Address - Phone:414-334-5224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-04
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2900134146N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic