Individual
KELSO LYNNE-BORRELL BLAZE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
2530 N HOWARD ST UNIT 2, PHILADELPHIA, PA 19133
(732) 744-4962
Mailing address
2530 N HOWARD ST UNIT 2, PHILADELPHIA, PA 19133
(732) 744-4962
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
5306693119
—
PA
Enumeration date
11/01/2021
Last updated
11/01/2021
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