Provider Demographics
NPI:1144581976
Name:BLAKE, DIANE M
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:M
Last Name:BLAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 COMUS RD
Mailing Address - Street 2:
Mailing Address - City:ROCKY POINT
Mailing Address - State:NY
Mailing Address - Zip Code:11778-9541
Mailing Address - Country:US
Mailing Address - Phone:631-821-3746
Mailing Address - Fax:
Practice Address - Street 1:1 COMUS RD
Practice Address - Street 2:
Practice Address - City:ROCKY POINT
Practice Address - State:NY
Practice Address - Zip Code:11778-9541
Practice Address - Country:US
Practice Address - Phone:631-821-3746
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-07
Last Update Date:2012-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist