Basic Information
| Provider Information | |||||||||
| NPI: | 1255829966 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLAISE | ||||||||
| FirstName: | DANICE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD,MBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6675 WESTWOOD BLVD STE 475 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328216027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4078450330 | ||||||||
| FaxNumber: | 8889721752 | ||||||||
| Practice Location | |||||||||
| Address1: | 684 STATE ROAD 60 W | ||||||||
| Address2: | |||||||||
| City: | LAKE WALES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338534419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8639494868 | ||||||||
| FaxNumber: | 8632238549 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2018 | ||||||||
| LastUpdateDate: | 10/27/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 2019045102 | MO | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | CV2000213 | IN | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208D00000X | ACN1418 | FL | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 115752400 | 05 | FL | MEDICAID |