Provider Demographics
NPI:1770007452
Name:EMBREY, BLAKE ANDREW
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:ANDREW
Last Name:EMBREY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:423 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:COLDWATER
Mailing Address - State:MS
Mailing Address - Zip Code:38618-3915
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:423 CENTRAL AVENUE
Practice Address - Street 2:
Practice Address - City:COLDWATER
Practice Address - State:MS
Practice Address - Zip Code:38618
Practice Address - Country:US
Practice Address - Phone:662-622-7011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-03
Last Update Date:2017-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS902101363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner