Provider Demographics
NPI:1306215074
Name:BLAKE, TYSHA TASHANNA (RN)
Entity Type:Individual
Prefix:MISS
First Name:TYSHA
Middle Name:TASHANNA
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 1:1293 CHISHOLM ST
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10459-1711
Mailing Address - Country:US
Mailing Address - Phone:718-825-7155
Mailing Address - Fax:
Practice Address - Street 1:1293 CHISHOLM ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10459-1711
Practice Address - Country:US
Practice Address - Phone:718-825-7155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-23
Last Update Date:2020-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY793156-01163W00000X
NY321921-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse