Provider Demographics
NPI:1073609301
Name:BLAKE, KATHERINE A (APRN BC)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:A
Last Name:BLAKE
Suffix:
Gender:F
Credentials:APRN BC
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:A
Other - Last Name:GENDRON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:55 PLEASANT STREET
Mailing Address - Street 2:
Mailing Address - City:NEWBURY PORT
Mailing Address - State:MA
Mailing Address - Zip Code:01950
Mailing Address - Country:US
Mailing Address - Phone:978-462-0302
Mailing Address - Fax:978-499-0226
Practice Address - Street 1:55 PLEASANT STREET
Practice Address - Street 2:
Practice Address - City:NEWBURY PORT
Practice Address - State:MA
Practice Address - Zip Code:01950
Practice Address - Country:US
Practice Address - Phone:978-462-0302
Practice Address - Fax:978-499-0226
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA104897364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAPN0059OtherBCBS
MA708967OtherTUFTS
R93953Medicare UPIN
MAPN0059Medicare ID - Type Unspecified