Provider Demographics
NPI:1740001965
Name:BLAKE, AMANDA (PMHNP)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:BLAKE
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2775 NW 49TH AVE UNIT 205
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34482-6213
Mailing Address - Country:US
Mailing Address - Phone:480-868-0228
Mailing Address - Fax:
Practice Address - Street 1:2775 NW 49TH AVE UNIT 205
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34482-6213
Practice Address - Country:US
Practice Address - Phone:480-868-0228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-21
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11036092363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health