Provider Demographics
NPI:1548602717
Name:BLAKES, NETTA L
Entity Type:Individual
Prefix:MRS
First Name:NETTA
Middle Name:L
Last Name:BLAKES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4186 STATE ROUTE 414
Mailing Address - Street 2:
Mailing Address - City:SENECA FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:13148-9530
Mailing Address - Country:US
Mailing Address - Phone:315-536-2601
Mailing Address - Fax:
Practice Address - Street 1:270 LAKE ST
Practice Address - Street 2:
Practice Address - City:PENN YAN
Practice Address - State:NY
Practice Address - Zip Code:14527-1832
Practice Address - Country:US
Practice Address - Phone:315-536-2601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-29
Last Update Date:2013-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY889913174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist