Provider Demographics
NPI:1508643750
Name:BLAKE, JENNIFER LEE (NP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEE
Last Name:BLAKE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LEE
Other - Last Name:WALLINGTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:159 ANNA FARM RD E
Mailing Address - Street 2:
Mailing Address - City:NORTH STONINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06359-1035
Mailing Address - Country:US
Mailing Address - Phone:401-741-9862
Mailing Address - Fax:
Practice Address - Street 1:71 HAYNES ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040-4188
Practice Address - Country:US
Practice Address - Phone:860-646-1222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-12
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT12319363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care