Provider Demographics
NPI:1740063148
Name:WILLIAMS BLAKE, ALYSSA
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:WILLIAMS BLAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3626 N SHERIDAN RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61604-1401
Mailing Address - Country:US
Mailing Address - Phone:309-308-5100
Mailing Address - Fax:
Practice Address - Street 1:3626 N SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61604-1401
Practice Address - Country:US
Practice Address - Phone:309-308-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-17
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209030189363LA2100X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program