Provider Demographics
NPI:1184213407
Name:BLAKE, DENNIS WAYNE
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:WAYNE
Last Name:BLAKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:285 GOOSEMAN LN
Mailing Address - Street 2:
Mailing Address - City:MOUNDSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26041-2363
Mailing Address - Country:US
Mailing Address - Phone:304-843-0910
Mailing Address - Fax:
Practice Address - Street 1:87 SWIERKOS DR
Practice Address - Street 2:
Practice Address - City:MOUNDSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26041-4209
Practice Address - Country:US
Practice Address - Phone:304-843-0910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-12
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1255523494Medicaid
WV1821206228Medicaid