Provider Demographics
NPI:1760872493
Name:BLAKEMORE, TANYA
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:BLAKEMORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TANYA
Other - Middle Name:
Other - Last Name:FLORES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:337 E PALMETTO AVE
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32750-4277
Mailing Address - Country:US
Mailing Address - Phone:321-614-4217
Mailing Address - Fax:
Practice Address - Street 1:337 E PALMETTO AVE
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32750-4277
Practice Address - Country:US
Practice Address - Phone:321-614-4217
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-03
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator