Provider Demographics
NPI:1275245912
Name:BLAKE, MARY A (RN)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:A
Last Name:BLAKE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 COLLIERS WAY
Mailing Address - Street 2:
Mailing Address - City:WEIRTON
Mailing Address - State:WV
Mailing Address - Zip Code:26062-5014
Mailing Address - Country:US
Mailing Address - Phone:304-797-6495
Mailing Address - Fax:
Practice Address - Street 1:601 COLLIERS WAY
Practice Address - Street 2:
Practice Address - City:WEIRTON
Practice Address - State:WV
Practice Address - Zip Code:26062-5014
Practice Address - Country:US
Practice Address - Phone:304-797-6495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-14
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV42708163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management