Provider Demographics
NPI:1942749965
Name:BLAKE, JUDITH ELISE (PA-C)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:ELISE
Last Name:BLAKE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1505 DAPHNE AVE
Mailing Address - Street 2:
Mailing Address - City:DAPHNE
Mailing Address - State:AL
Mailing Address - Zip Code:36526-4298
Mailing Address - Country:US
Mailing Address - Phone:251-625-2663
Mailing Address - Fax:251-625-3198
Practice Address - Street 1:1505 DAPHNE AVE
Practice Address - Street 2:
Practice Address - City:DAPHNE
Practice Address - State:AL
Practice Address - Zip Code:36526-4298
Practice Address - Country:US
Practice Address - Phone:251-625-2663
Practice Address - Fax:251-625-3198
Is Sole Proprietor?:No
Enumeration Date:2017-02-23
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA.1207363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical