Provider Demographics
NPI:1629379789
Name:BLAKE, DANA CROSBY (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MRS
First Name:DANA
Middle Name:CROSBY
Last Name:BLAKE
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 91734
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23291-1734
Mailing Address - Country:US
Mailing Address - Phone:804-358-6100
Mailing Address - Fax:804-342-7619
Practice Address - Street 1:1250 E MARSHALL ST
Practice Address - Street 2:NEUROLOGY
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23298-5051
Practice Address - Country:US
Practice Address - Phone:804-828-7999
Practice Address - Fax:804-828-1151
Is Sole Proprietor?:No
Enumeration Date:2010-11-05
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0001117856163W00000X
VA0024169011363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1629379789Medicaid
VA1629379789Medicaid
VAP00914002Medicare PIN