Provider Demographics
NPI:1003055591
Name:SLACK, BLAKE RAINIE (CNM, WHNP)
Entity Type:Individual
Prefix:MRS
First Name:BLAKE
Middle Name:RAINIE
Last Name:SLACK
Suffix:
Gender:F
Credentials:CNM, WHNP
Other - Prefix:MS
Other - First Name:BLAKE
Other - Middle Name:ELIZABETH
Other - Last Name:RAINIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNM, WHNP
Mailing Address - Street 1:55 FRUIT ST, FOUNDERS 454
Mailing Address - Street 2:MASSACHUSETTS GENERAL HOSPITAL
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-2621
Mailing Address - Country:US
Mailing Address - Phone:617-726-2033
Mailing Address - Fax:
Practice Address - Street 1:55 FRUIT ST, FOUNDERS 454
Practice Address - Street 2:MASSACHUSETTS GENERAL HOSPITAL
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2621
Practice Address - Country:US
Practice Address - Phone:617-726-2033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-07
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAC000650176B00000X
MA283129176B00000X
MARN283129367A00000X, 363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No176B00000XOther Service ProvidersMidwife
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health