Provider Demographics
NPI:1164835229
Name:BLAKE, LOREN
Entity Type:Individual
Prefix:
First Name:LOREN
Middle Name:
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 1:213 WINDING POND RD
Mailing Address - Street 2:
Mailing Address - City:LONDONDERRY
Mailing Address - State:NH
Mailing Address - Zip Code:03053-3378
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:213 WINDING POND RD
Practice Address - Street 2:
Practice Address - City:LONDONDERRY
Practice Address - State:NH
Practice Address - Zip Code:03053-3378
Practice Address - Country:US
Practice Address - Phone:603-490-7107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-06
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY284393208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice