Provider Demographics
NPI:1184096729
Name:BLAKE, SANDRA LEE (RD, LD)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:LEE
Last Name:BLAKE
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:LEE
Other - Last Name:FAIT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:45 10TH ST W
Mailing Address - Street 2:NUTRITION SERVICES G447
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102-1062
Mailing Address - Country:US
Mailing Address - Phone:651-232-3463
Mailing Address - Fax:651-326-8783
Practice Address - Street 1:45 10TH ST W
Practice Address - Street 2:NUTRITION SERVICES G447
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-1062
Practice Address - Country:US
Practice Address - Phone:651-232-3463
Practice Address - Fax:651-326-8783
Is Sole Proprietor?:No
Enumeration Date:2015-10-22
Last Update Date:2015-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1424133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered