Provider Demographics
NPI:1609426261
Name:BLAKE, JOHANNAH (PMHNP-BC)
Entity Type:Individual
Prefix:MS
First Name:JOHANNAH
Middle Name:
Last Name:BLAKE
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:975 N SILVERBELL RD UNIT 85194
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85754-4009
Mailing Address - Country:US
Mailing Address - Phone:520-861-4414
Mailing Address - Fax:
Practice Address - Street 1:3814 E 5TH ST
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85716-5145
Practice Address - Country:US
Practice Address - Phone:520-372-8575
Practice Address - Fax:520-372-8576
Is Sole Proprietor?:No
Enumeration Date:2019-09-16
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ229492363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health