Provider Demographics
NPI:1710457635
Name:BLAKE, ANGELA VELMARIE
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:VELMARIE
Last Name:BLAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 PEARSALL DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10552-3945
Mailing Address - Country:US
Mailing Address - Phone:347-276-4146
Mailing Address - Fax:
Practice Address - Street 1:180 PEARSALL DR
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:NY
Practice Address - Zip Code:10552-3945
Practice Address - Country:US
Practice Address - Phone:347-276-4146
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-04
Last Update Date:2018-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY453733163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse