Individual
DR. DANICE BLAISE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MD,MBA
Contact information
Practice address
684 STATE ROAD 60 W, LAKE WALES, FL 33853-4419
(863) 949-4868
(863) 223-8549
Mailing address
6675 WESTWOOD BLVD STE 475, ORLANDO, FL 32821-6027
(407) 845-0330
(888) 972-1752
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
25173
NH
208D00000X
General Practice Physician
Primary
ACN1418
FL
363A00000X
Physician Assistant
2019045102
MO
363A00000X
Physician Assistant
CV2000213
IN
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
115752400
—
FL
Enumeration date
04/27/2018
Last updated
12/07/2024
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