Provider Demographics
NPI:1255990719
Name:BLAKE, BRIA NIKOLE WILLIAMS (MD)
Entity type:Individual
Prefix:DR
First Name:BRIA
Middle Name:NIKOLE WILLIAMS
Last Name:BLAKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1918 RANDOLPH RD STE 670
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1119
Practice Address - Country:US
Practice Address - Phone:704-384-1620
Practice Address - Fax:704-384-1626
Is Sole Proprietor?:No
Enumeration Date:2019-06-10
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLL82792207V00000X
NC2023-01746207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology