Provider Demographics
NPI:1013978535
Name:BLAKE, AMY SUSAN (FNP-BC)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:SUSAN
Last Name:BLAKE
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:MS
Other - First Name:AMY
Other - Middle Name:SUSAN
Other - Last Name:GEMMILL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-BC
Mailing Address - Street 1:129 CAMBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:LANDENBERG
Mailing Address - State:PA
Mailing Address - Zip Code:19350-1304
Mailing Address - Country:US
Mailing Address - Phone:302-757-0861
Mailing Address - Fax:
Practice Address - Street 1:680 BLAIR MILL RD
Practice Address - Street 2:
Practice Address - City:HORSHAM
Practice Address - State:PA
Practice Address - Zip Code:19044-2223
Practice Address - Country:US
Practice Address - Phone:302-304-6341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-01
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DELG-0000384363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1013978535Medicaid
DEG02723I25Medicare PIN