Provider Demographics
NPI:1871030262
Name:BLAKE, KRISTIE J (APRN-CNM)
Entity Type:Individual
Prefix:
First Name:KRISTIE
Middle Name:J
Last Name:BLAKE
Suffix:
Gender:F
Credentials:APRN-CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:700 ACKERMAN RD STE 2120
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43202-1559
Mailing Address - Country:US
Mailing Address - Phone:614-293-3069
Mailing Address - Fax:614-293-9684
Practice Address - Street 1:920 N HAMILTON RD STE 200
Practice Address - Street 2:
Practice Address - City:GAHANNA
Practice Address - State:OH
Practice Address - Zip Code:43230-1757
Practice Address - Country:US
Practice Address - Phone:614-293-3069
Practice Address - Fax:614-293-9684
Is Sole Proprietor?:No
Enumeration Date:2017-01-24
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.024341363LW0102X
OHAPRN.CNM.019312367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0303155Medicaid