Provider Demographics
NPI:1013142207
Name:BLAKE, SHAWNY JERRETTA (BCHIS)
Entity Type:Individual
Prefix:
First Name:SHAWNY
Middle Name:JERRETTA
Last Name:BLAKE
Suffix:
Gender:F
Credentials:BCHIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:913B SAINT FRANCIS ST
Mailing Address - Street 2:
Mailing Address - City:KENNETT
Mailing Address - State:MO
Mailing Address - Zip Code:63857-1779
Mailing Address - Country:US
Mailing Address - Phone:573-888-9881
Mailing Address - Fax:
Practice Address - Street 1:913B SAINT FRANCIS ST
Practice Address - Street 2:
Practice Address - City:KENNETT
Practice Address - State:MO
Practice Address - Zip Code:63857-1779
Practice Address - Country:US
Practice Address - Phone:573-888-9881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-18
Last Update Date:2009-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1003237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO401516OtherBLUE CROSS AND BLUE SHIELD