Provider Demographics
NPI:1598497984
Name:BLAKE, ERICA N (LPN)
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:N
Last Name:BLAKE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:158 HIGHLAWN AVE
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:WV
Mailing Address - Zip Code:25541-8553
Mailing Address - Country:US
Mailing Address - Phone:304-305-0875
Mailing Address - Fax:
Practice Address - Street 1:332 6TH AVE
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25303-1269
Practice Address - Country:US
Practice Address - Phone:304-757-9333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-26
Last Update Date:2022-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV32220164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse