Provider Demographics
NPI:1043629140
Name:BLAKE, OPAL MULLINGS (NP-C)
Entity Type:Individual
Prefix:
First Name:OPAL
Middle Name:MULLINGS
Last Name:BLAKE
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:631 PROFESSIONAL DR
Mailing Address - Street 2:SUITE 350
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046
Mailing Address - Country:US
Mailing Address - Phone:770-995-0630
Mailing Address - Fax:770-682-0088
Practice Address - Street 1:631 PROFESSIONAL DR STE 350
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-3370
Practice Address - Country:US
Practice Address - Phone:770-995-0630
Practice Address - Fax:770-995-1555
Is Sole Proprietor?:No
Enumeration Date:2014-08-04
Last Update Date:2016-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN 199200363L00000X
GARN199200363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner