Provider Demographics
NPI:1689971749
Name:BLAKE, KIMBERLY LORENE (FNP-C)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:LORENE
Last Name:BLAKE
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1125 SKYLINE DR
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72032-2857
Mailing Address - Country:US
Mailing Address - Phone:501-358-6120
Mailing Address - Fax:501-358-6268
Practice Address - Street 1:1125 SKYLINE DR
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72032-6657
Practice Address - Country:US
Practice Address - Phone:501-358-6120
Practice Address - Fax:501-358-6268
Is Sole Proprietor?:No
Enumeration Date:2011-02-24
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA03482 ANP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily