Provider Demographics
NPI:1568148336
Name:DALY, BLAKE (RD)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:DALY
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 SOUTH 28TH AVENUE HATTIESBURG
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401
Mailing Address - Country:US
Mailing Address - Phone:601-579-5210
Mailing Address - Fax:601-268-5733
Practice Address - Street 1:19333 BEAR VALLEY RD STE 103
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92308-5149
Practice Address - Country:US
Practice Address - Phone:714-618-9500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-26
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSD-2197133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered