Provider Demographics
NPI:1942079280
Name:BLAKE, TAMARA NICOLE
Entity Type:Individual
Prefix:MRS
First Name:TAMARA
Middle Name:NICOLE
Last Name:BLAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:TAMARA
Other - Middle Name:NICOLE
Other - Last Name:HARDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7430 RADFORD TRL
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78244-2231
Mailing Address - Country:US
Mailing Address - Phone:210-385-5287
Mailing Address - Fax:
Practice Address - Street 1:7430 RADFORD TRL
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78244-2231
Practice Address - Country:US
Practice Address - Phone:210-385-5287
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-28
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX866117163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse