Provider Demographics
NPI:1609279082
Name:BLAKE, STACEY KATHLEEN (APRN, FNP-C)
Entity Type:Individual
Prefix:MS
First Name:STACEY
Middle Name:KATHLEEN
Last Name:BLAKE
Suffix:
Gender:F
Credentials:APRN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2201 REGENCY RD
Mailing Address - Street 2:SUITE 501
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-2335
Mailing Address - Country:US
Mailing Address - Phone:859-523-7398
Mailing Address - Fax:859-687-9648
Practice Address - Street 1:1250 PINE RIDGE RD STE 101B
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34108-8913
Practice Address - Country:US
Practice Address - Phone:239-919-7009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-30
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3008973363L00000X, 363LF0000X
FL9467859363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100356460Medicaid
KY7100356460Medicaid
KYK163211Medicare PIN