Provider Demographics
NPI:1396363438
Name:WILLIAMS, BLAKE MCCULLOUGH (FNP)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:MCCULLOUGH
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:335 CARTER RD
Mailing Address - Street 2:
Mailing Address - City:DRY CREEK
Mailing Address - State:LA
Mailing Address - Zip Code:70637-5029
Mailing Address - Country:US
Mailing Address - Phone:318-308-4063
Mailing Address - Fax:
Practice Address - Street 1:1017 N PINE ST
Practice Address - Street 2:
Practice Address - City:DERIDDER
Practice Address - State:LA
Practice Address - Zip Code:70634-2817
Practice Address - Country:US
Practice Address - Phone:337-202-4101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-06
Last Update Date:2020-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA214331363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care