Provider Demographics
NPI:1013394402
Name:BLAKE, ASHLEY HARRIS (LPN)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:HARRIS
Last Name:BLAKE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:DEONNE
Other - Last Name:HARRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1096 JOAQUIN RD
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32506-8311
Mailing Address - Country:US
Mailing Address - Phone:954-600-8452
Mailing Address - Fax:
Practice Address - Street 1:1096 JOAQUIN RD
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32506-8311
Practice Address - Country:US
Practice Address - Phone:954-600-8452
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-05
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL5212236164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse