Provider Demographics
NPI:1184984536
Name:BLAKE, CHIQUITA
Entity type:Individual
Prefix:
First Name:CHIQUITA
Middle Name:
Last Name:BLAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 WOODBINE ST
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17110-1857
Mailing Address - Country:US
Mailing Address - Phone:717-585-9390
Mailing Address - Fax:717-889-0254
Practice Address - Street 1:340 WOODBINE ST
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17110-1857
Practice Address - Country:US
Practice Address - Phone:717-585-9390
Practice Address - Fax:717-889-0254
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-19
Last Update Date:2012-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA9974394372500000X, 374U00000X, 376J00000X, 376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
No372500000XNursing Service Related ProvidersChore Provider
No374U00000XNursing Service Related ProvidersHome Health Aide
No376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA4090262OtherSTATE BUSINESS ENTITY NUMBER