Provider Demographics
NPI:1073678785
Name:CAROL BLAKE, MSN, RN, CNS, CRNFA, CNOR, PC
Entity Type:Organization
Organization Name:CAROL BLAKE, MSN, RN, CNS, CRNFA, CNOR, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:BLAKE
Authorized Official - Suffix:
Authorized Official - Credentials:CNS, CRNFA
Authorized Official - Phone:602-971-8599
Mailing Address - Street 1:4091 E NISBET RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-4767
Mailing Address - Country:US
Mailing Address - Phone:602-971-8588
Mailing Address - Fax:602-971-3887
Practice Address - Street 1:4091 E NISBET RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-4767
Practice Address - Country:US
Practice Address - Phone:602-971-8588
Practice Address - Fax:602-971-3887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN036821364SP2800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SP2800XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPerioperativeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZNPP000Medicare UPIN
AZ23951Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER