Provider Demographics
NPI:1972666154
Name:BLAKE, CHARLES EDWARD (FNP-BC)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:EDWARD
Last Name:BLAKE
Suffix:
Gender:M
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:322 W ORCHID LN
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85021-4543
Mailing Address - Country:US
Mailing Address - Phone:602-689-6118
Mailing Address - Fax:602-938-7277
Practice Address - Street 1:3141 N 3RD AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-4351
Practice Address - Country:US
Practice Address - Phone:602-689-6118
Practice Address - Fax:602-938-7277
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP2395363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily