Provider Demographics
NPI:1811415409
Name:BLAKE, KIRSTEN EMILY
Entity Type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:EMILY
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 1:16755 WOODLAND CT
Mailing Address - Street 2:
Mailing Address - City:BRIDGEVILLE
Mailing Address - State:DE
Mailing Address - Zip Code:19933-3900
Mailing Address - Country:US
Mailing Address - Phone:302-752-6100
Mailing Address - Fax:
Practice Address - Street 1:16755 WOODLAND CT
Practice Address - Street 2:
Practice Address - City:BRIDGEVILLE
Practice Address - State:DE
Practice Address - Zip Code:19933-3900
Practice Address - Country:US
Practice Address - Phone:302-752-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-02
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
VA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer