Provider Demographics
NPI:1710937073
Name:BLAKE REEVES, MARY L
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:L
Last Name:BLAKE REEVES
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 1:5535 DELMAR BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63112-3005
Mailing Address - Country:US
Mailing Address - Phone:314-879-6300
Mailing Address - Fax:314-879-6372
Practice Address - Street 1:4626 LEE AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63115-2431
Practice Address - Country:US
Practice Address - Phone:314-385-7726
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO068911363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO815032931Medicaid
MO427399902Medicaid
MO1710937073OtherNATIONAL PROVIDER IDENTIFIER
MO11646789OtherCAQH
MO11646789OtherCAQH