Provider Demographics
NPI:1336658707
Name:BLAKE, LATOYA
Entity Type:Individual
Prefix:
First Name:LATOYA
Middle Name:
Last Name:BLAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 ELISE LN
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:TN
Mailing Address - Zip Code:37148-2200
Mailing Address - Country:US
Mailing Address - Phone:615-440-0127
Mailing Address - Fax:
Practice Address - Street 1:104 ELISE LN
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:TN
Practice Address - Zip Code:37148-2200
Practice Address - Country:US
Practice Address - Phone:615-440-0127
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-28
Last Update Date:2017-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health