Provider Demographics
NPI:1033252218
Name:BLAKE, LEILA ICILLDA (LPN)
Entity Type:Individual
Prefix:MS
First Name:LEILA
Middle Name:ICILLDA
Last Name:BLAKE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 15 194 STREET
Mailing Address - Street 2:SPRINGFIELD GARDENS
Mailing Address - City:QUEENS
Mailing Address - State:NY
Mailing Address - Zip Code:11413
Mailing Address - Country:US
Mailing Address - Phone:718-949-3421
Mailing Address - Fax:
Practice Address - Street 1:121 15 194 STREET
Practice Address - Street 2:SPRINGFIELD GARDENS
Practice Address - City:QUEENS
Practice Address - State:NY
Practice Address - Zip Code:11413
Practice Address - Country:US
Practice Address - Phone:718-949-3421
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1651541164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02570390Medicaid