Provider Demographics
NPI:1821659921
Name:BLAKE, EMILY KATHERINE
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:KATHERINE
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 1:12 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:HOPKINTON
Mailing Address - State:MA
Mailing Address - Zip Code:01748-2569
Mailing Address - Country:US
Mailing Address - Phone:774-279-6868
Mailing Address - Fax:
Practice Address - Street 1:12 JACKSON ST
Practice Address - Street 2:
Practice Address - City:HOPKINTON
Practice Address - State:MA
Practice Address - Zip Code:01748-2569
Practice Address - Country:US
Practice Address - Phone:774-279-6868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-28
Last Update Date:2019-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA201913741363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics