Provider Demographics
NPI:1639103237
Name:BLAKE, ELIZABETH MIYU (ARNP)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:MIYU
Last Name:BLAKE
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:LARSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:128 WOODLAND AVE
Mailing Address - Street 2:
Mailing Address - City:PORT TOWNSEND
Mailing Address - State:WA
Mailing Address - Zip Code:98368-5049
Mailing Address - Country:US
Mailing Address - Phone:206-422-4035
Mailing Address - Fax:
Practice Address - Street 1:301 N 10TH AVE
Practice Address - Street 2:
Practice Address - City:PASCO
Practice Address - State:WA
Practice Address - Zip Code:99301-5480
Practice Address - Country:US
Practice Address - Phone:509-547-2429
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00118189363LP0200X
WAAP30003638363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAP30003638OtherARNP LICENSE
WA9620097Medicaid
WARN00118189OtherRN LICENSE
WARN00118189OtherRN LICENSE
WA9620097Medicaid