Provider Demographics
NPI:1992360630
Name:BLAKE, CHERYL NADINE (NP)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:NADINE
Last Name:BLAKE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:CHERYL
Other - Middle Name:CALLAHAN
Other - Last Name:BLAKE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:3560 W CABELLA DR
Mailing Address - Street 2:
Mailing Address - City:SULPHUR
Mailing Address - State:LA
Mailing Address - Zip Code:70665-8774
Mailing Address - Country:US
Mailing Address - Phone:337-244-4622
Mailing Address - Fax:
Practice Address - Street 1:707 E PRIEN LAKE RD STE A
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-8788
Practice Address - Country:US
Practice Address - Phone:337-475-3200
Practice Address - Fax:337-475-3222
Is Sole Proprietor?:No
Enumeration Date:2019-05-08
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA203900363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner