Provider Demographics
NPI:1912567041
Name:BLAKE, NOLAN SCOTT
Entity Type:Individual
Prefix:MR
First Name:NOLAN
Middle Name:SCOTT
Last Name:BLAKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4926 RIDGELEY DR.
Mailing Address - Street 2:SUITE B
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28208
Mailing Address - Country:US
Mailing Address - Phone:704-910-0073
Mailing Address - Fax:704-910-0055
Practice Address - Street 1:4926 RIDGELEY DR.
Practice Address - Street 2:SUITE B
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28208
Practice Address - Country:US
Practice Address - Phone:704-910-0073
Practice Address - Fax:704-910-0055
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-20
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care