Provider Demographics
NPI:1245631019
Name:BLAKE, BREANNE M (PA-C)
Entity type:Individual
Prefix:MRS
First Name:BREANNE
Middle Name:M
Last Name:BLAKE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 NOLTE DR
Mailing Address - Street 2:
Mailing Address - City:KITTANNING
Mailing Address - State:PA
Mailing Address - Zip Code:16201-7111
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10261 PA-85
Practice Address - Street 2:
Practice Address - City:KITTANNING
Practice Address - State:PA
Practice Address - Zip Code:16201
Practice Address - Country:US
Practice Address - Phone:724-783-7124
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-11
Last Update Date:2025-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA057085363AM0700X
OA004127363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical