Provider Demographics
NPI:1205585874
Name:KOCEJA, BLAKE DANIEL (FNP-C)
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:DANIEL
Last Name:KOCEJA
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5150 WAKEHURST ST
Mailing Address - Street 2:
Mailing Address - City:KANNAPOLIS
Mailing Address - State:NC
Mailing Address - Zip Code:28081-6512
Mailing Address - Country:US
Mailing Address - Phone:704-706-7446
Mailing Address - Fax:
Practice Address - Street 1:1583 HEALTH CARE DR
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-3858
Practice Address - Country:US
Practice Address - Phone:704-706-7446
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-22
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC27865363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty