Provider Demographics
NPI:1114359726
Name:BLAKE, MANDY (PNP)
Entity Type:Individual
Prefix:
First Name:MANDY
Middle Name:
Last Name:BLAKE
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 WOODSON ST
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:NC
Mailing Address - Zip Code:28144-3255
Mailing Address - Country:US
Mailing Address - Phone:704-636-5576
Mailing Address - Fax:704-216-2011
Practice Address - Street 1:129 WOODSON ST
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28144-3255
Practice Address - Country:US
Practice Address - Phone:704-636-5576
Practice Address - Fax:704-216-2011
Is Sole Proprietor?:No
Enumeration Date:2013-08-06
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5006329363L00000X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner