Provider Demographics
NPI:1629329453
Name:BLAKE, PHYLLISA DAWN (RN)
Entity Type:Individual
Prefix:
First Name:PHYLLISA
Middle Name:DAWN
Last Name:BLAKE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4312 RICKENBACKER WAY NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-3713
Mailing Address - Country:US
Mailing Address - Phone:404-914-7136
Mailing Address - Fax:
Practice Address - Street 1:3807 CLAIRMONT RD
Practice Address - Street 2:
Practice Address - City:CHAMBLEE
Practice Address - State:GA
Practice Address - Zip Code:30341-4911
Practice Address - Country:US
Practice Address - Phone:770-454-1144
Practice Address - Fax:770-452-4468
Is Sole Proprietor?:No
Enumeration Date:2012-09-19
Last Update Date:2012-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN196553163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse