Provider Demographics
NPI:1730907510
Name:DAVIS-BLAIZE, MONIQUE (RN)
Entity type:Individual
Prefix:
First Name:MONIQUE
Middle Name:
Last Name:DAVIS-BLAIZE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 SUNNYFIELD RD
Mailing Address - Street 2:
Mailing Address - City:CAMILLUS
Mailing Address - State:NY
Mailing Address - Zip Code:13031-1832
Mailing Address - Country:US
Mailing Address - Phone:347-622-0379
Mailing Address - Fax:
Practice Address - Street 1:620 MADISON ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-2319
Practice Address - Country:US
Practice Address - Phone:315-426-3600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-30
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY633902163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse