Provider Demographics
NPI:1659568871
Name:BLAKE, CARRIE VALENTINE (CPM, LM)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:VALENTINE
Last Name:BLAKE
Suffix:
Gender:F
Credentials:CPM, LM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1315 S SAINT FRANCIS DR
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-4035
Mailing Address - Country:US
Mailing Address - Phone:505-780-5030
Mailing Address - Fax:
Practice Address - Street 1:1315 S SAINT FRANCIS DR
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4035
Practice Address - Country:US
Practice Address - Phone:505-780-5030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-02
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID27176B00000X
NM20001R176B00000X
CO97176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
11872716OtherCAQH