Provider Demographics
NPI:1003496829
Name:JANICE BLAKE APRN, PLLC
Entity Type:Organization
Organization Name:JANICE BLAKE APRN, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:
Authorized Official - Last Name:BLAKE
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC
Authorized Official - Phone:860-266-7826
Mailing Address - Street 1:181 THOMPSON ST
Mailing Address - Street 2:
Mailing Address - City:S GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06073-2919
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:181 THOMPSON ST
Practice Address - Street 2:
Practice Address - City:S GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06073-2919
Practice Address - Country:US
Practice Address - Phone:860-266-7826
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-14
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty