Provider Demographics
NPI:1356999387
Name:REDDICK, BLAKE
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:REDDICK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10755 FALLS RD
Mailing Address - Street 2:
Mailing Address - City:LUTHERVILLE TIMONIUM
Mailing Address - State:MD
Mailing Address - Zip Code:21093-4515
Mailing Address - Country:US
Mailing Address - Phone:410-616-7350
Mailing Address - Fax:
Practice Address - Street 1:10755 FALLS RD
Practice Address - Street 2:
Practice Address - City:LUTHERVILLE TIMONIUM
Practice Address - State:MD
Practice Address - Zip Code:21093-4515
Practice Address - Country:US
Practice Address - Phone:410-616-7350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-03
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR243734163W00000X, 363LA2200X
IL041446406163WG0000X
IN28235378A163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice