Provider Demographics
NPI:1770538977
Name:BLAKE, PAMELA J (CRNP)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:J
Last Name:BLAKE
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 55310
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35255-5310
Mailing Address - Country:US
Mailing Address - Phone:205-731-9701
Mailing Address - Fax:
Practice Address - Street 1:619 19TH ST S
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35249-1900
Practice Address - Country:US
Practice Address - Phone:205-934-6600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-24
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1054391363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL891007690Medicaid
AL051521386OtherBLUE CROSS
AL891007670Medicaid
AL891007710Medicaid
AL891007720Medicaid
AL891007730Medicaid
AL051521388OtherBLUE CROSS
AL891007680Medicaid
AL051521387OtherBLUE CROSS
AL051521389OtherBLUE CROSS
AL051521390OtherBLUE CROSS
AL051521392OtherBLUE CROSS
AL051554939OtherBLUE CROSS
AL051521391OtherBLUE CROSS
AL891007700Medicaid