Provider Demographics
NPI:1841804960
Name:BLAKE, CLAUDETTE L (APRN)
Entity Type:Individual
Prefix:MRS
First Name:CLAUDETTE
Middle Name:L
Last Name:BLAKE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1199 ROUTE 22
Mailing Address - Street 2:
Mailing Address - City:MOUNTAINSIDE
Mailing Address - State:NJ
Mailing Address - Zip Code:07092-2807
Mailing Address - Country:US
Mailing Address - Phone:908-228-5100
Mailing Address - Fax:
Practice Address - Street 1:1199 ROUTE 22
Practice Address - Street 2:
Practice Address - City:MOUNTAINSIDE
Practice Address - State:NJ
Practice Address - Zip Code:07092-2807
Practice Address - Country:US
Practice Address - Phone:908-228-5100
Practice Address - Fax:908-228-5115
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-04
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ01050200363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health