Provider Demographics
NPI:1679955462
Name:BLAKE, DESIREE JE (CNM)
Entity Type:Individual
Prefix:MS
First Name:DESIREE
Middle Name:JE
Last Name:BLAKE
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 S 3RD ST STE 210
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-4206
Mailing Address - Country:US
Mailing Address - Phone:888-731-8994
Mailing Address - Fax:
Practice Address - Street 1:20 S 3RD ST STE 210
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-4206
Practice Address - Country:US
Practice Address - Phone:888-731-8994
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-29
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN365269163W00000X
OHAPRNCNP020755363LF0000X
PAMW010644367A00000X
OHCOA17863NM367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty