Provider Demographics
NPI:1356603906
Name:BLAKE, KARA (NP)
Entity type:Individual
Prefix:
First Name:KARA
Middle Name:
Last Name:BLAKE
Suffix:
Gender:
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2017 GRAND AVE APT D
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10453-4650
Mailing Address - Country:US
Mailing Address - Phone:646-623-4429
Mailing Address - Fax:
Practice Address - Street 1:2017 GRAND AVE APT D
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10453-4650
Practice Address - Country:US
Practice Address - Phone:646-623-4429
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-11
Last Update Date:2025-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF356628-01363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner