Provider Demographics
NPI:1881006674
Name:BLAKE, RANDY (RN)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:
Last Name:BLAKE
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:735 N NEIL ST
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91791-1120
Mailing Address - Country:US
Mailing Address - Phone:626-780-4170
Mailing Address - Fax:
Practice Address - Street 1:550 S VERMONT AVE FL 10
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90020-1912
Practice Address - Country:US
Practice Address - Phone:310-217-7312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-28
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA563948163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health