Provider Demographics
NPI:1689928582
Name:BLAKE, HALEY ELISE (FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:HALEY
Middle Name:ELISE
Last Name:BLAKE
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1836 W GEORGIA RD
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29680-7212
Mailing Address - Country:US
Mailing Address - Phone:864-675-1700
Mailing Address - Fax:864-675-1705
Practice Address - Street 1:1836 W GEORGIA RD
Practice Address - Street 2:
Practice Address - City:SIMPSONVILLE
Practice Address - State:SC
Practice Address - Zip Code:29680-7212
Practice Address - Country:US
Practice Address - Phone:864-675-1700
Practice Address - Fax:864-675-1705
Is Sole Proprietor?:No
Enumeration Date:2012-10-31
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC18023363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily