Provider Demographics
NPI:1689626319
Name:BLAKE, KIMBERLY A (ANP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:A
Last Name:BLAKE
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 CALVERT ST
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:NY
Mailing Address - Zip Code:10528-3131
Mailing Address - Country:US
Mailing Address - Phone:914-241-1050
Mailing Address - Fax:914-242-1516
Practice Address - Street 1:106 CALVERT ST
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:NY
Practice Address - Zip Code:10528-3131
Practice Address - Country:US
Practice Address - Phone:914-835-0073
Practice Address - Fax:914-835-1071
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2020-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF302529363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0667910001OtherDME
NY02073710Medicaid
NY02073710Medicaid
NY0667910001OtherDME