Provider Demographics
NPI:1629435359
Name:BLAKE, ELIZABETH (MPH, RDN)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:BLAKE
Suffix:
Gender:F
Credentials:MPH, RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16301 EAGLE LN
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92649-2715
Mailing Address - Country:US
Mailing Address - Phone:562-619-6272
Mailing Address - Fax:
Practice Address - Street 1:16301 EAGLE LN
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92649-2715
Practice Address - Country:US
Practice Address - Phone:562-619-6272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-26
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered