Provider Demographics
NPI:1467062950
Name:BLAKE, AMY JOSEPHINE (NP-C)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:JOSEPHINE
Last Name:BLAKE
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1210 JUNCTION ST
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-1134
Mailing Address - Country:US
Mailing Address - Phone:248-229-2893
Mailing Address - Fax:
Practice Address - Street 1:4100 JOHN R ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2013
Practice Address - Country:US
Practice Address - Phone:800-527-6266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-09
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704322193363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner