Provider Demographics
NPI:1497275804
Name:MCKNIGHT, BLAKE COULTER (NP)
Entity Type:Individual
Prefix:MR
First Name:BLAKE
Middle Name:COULTER
Last Name:MCKNIGHT
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:272 NORTH MAIN STREET #101
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:VT
Mailing Address - Zip Code:05444
Mailing Address - Country:US
Mailing Address - Phone:802-644-5114
Mailing Address - Fax:
Practice Address - Street 1:272 NORTH MAIN STREET
Practice Address - Street 2:#101
Practice Address - City:CAMBRIDGE
Practice Address - State:VT
Practice Address - Zip Code:05444
Practice Address - Country:US
Practice Address - Phone:802-644-5114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-27
Last Update Date:2017-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT101.0129624363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily