Provider Demographics
NPI:1740644467
Name:BLAKE, ANGELA
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name: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 1:930 RAZ AVE
Mailing Address - Street 2:
Mailing Address - City:NEW WINDSOR
Mailing Address - State:NY
Mailing Address - Zip Code:12553-4705
Mailing Address - Country:US
Mailing Address - Phone:845-564-1855
Mailing Address - Fax:
Practice Address - Street 1:930 RAZ AVE
Practice Address - Street 2:
Practice Address - City:NEW WINDSOR
Practice Address - State:NY
Practice Address - Zip Code:12553-4705
Practice Address - Country:US
Practice Address - Phone:845-564-1855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-08
Last Update Date:2016-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist