Provider Demographics
NPI:1093385759
Name:BLAKE, TRACI A (RN)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:A
Last Name:BLAKE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5023 BUSH HILL RD
Mailing Address - Street 2:
Mailing Address - City:CANISTEO
Mailing Address - State:NY
Mailing Address - Zip Code:14823-9675
Mailing Address - Country:US
Mailing Address - Phone:607-968-4125
Mailing Address - Fax:
Practice Address - Street 1:5023 BUSH HILL RD
Practice Address - Street 2:
Practice Address - City:CANISTEO
Practice Address - State:NY
Practice Address - Zip Code:14823-9675
Practice Address - Country:US
Practice Address - Phone:607-968-4125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-25
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY804067-02163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health