Provider Demographics
NPI:1790553576
Name:BLAKE, KORI
Entity Type:Individual
Prefix:
First Name:KORI
Middle Name:
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 1:1107 GLEN DALE HEIGHTS RD
Mailing Address - Street 2:
Mailing Address - City:GLEN DALE
Mailing Address - State:WV
Mailing Address - Zip Code:26038-1092
Mailing Address - Country:US
Mailing Address - Phone:304-281-4344
Mailing Address - Fax:
Practice Address - Street 1:1107 GLEN DALE HEIGHTS RD
Practice Address - Street 2:
Practice Address - City:GLEN DALE
Practice Address - State:WV
Practice Address - Zip Code:26038-1092
Practice Address - Country:US
Practice Address - Phone:304-281-4344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-12
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant