Provider Demographics
NPI:1326037573
Name:BLAKE, LESLEY M (MD)
Entity Type:Individual
Prefix:DR
First Name:LESLEY
Middle Name:M
Last Name:BLAKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 800
Mailing Address - Street 2:
Mailing Address - City:MEDICAL LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99022-0800
Mailing Address - Country:US
Mailing Address - Phone:509-299-3121
Mailing Address - Fax:509-299-7015
Practice Address - Street 1:850 MAPLE STREET
Practice Address - Street 2:
Practice Address - City:MEDICAL LAKE
Practice Address - State:WA
Practice Address - Zip Code:99022
Practice Address - Country:US
Practice Address - Phone:509-299-3121
Practice Address - Fax:509-299-7015
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000435932084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8421471Medicaid
WA8804591Medicare PIN
WA13005Medicare UPIN