Provider Demographics
NPI:1457485682
Name:BLAKE, SHEILA D (RN, MNS,CPNP)
Entity Type:Individual
Prefix:
First Name:SHEILA
Middle Name:D
Last Name:BLAKE
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Gender:F
Credentials:RN, MNS,CPNP
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Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:1045 SOUTHCREST DR
Mailing Address - Street 2:SUITE 110
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-6113
Mailing Address - Country:US
Mailing Address - Phone:770-507-2212
Mailing Address - Fax:770-507-2213
Practice Address - Street 1:1045 SOUTHCREST DR
Practice Address - Street 2:SUITE 110
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-6113
Practice Address - Country:US
Practice Address - Phone:770-507-2212
Practice Address - Fax:770-507-2213
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2013-01-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA21932363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics