Provider Demographics
NPI:1780076224
Name:BLAKE, ELIZABETH (IBCLC)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:BLAKE
Suffix:
Gender:F
Credentials:IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9314 FOREST HILL BLVD STE 204
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33411-6577
Mailing Address - Country:US
Mailing Address - Phone:561-213-4944
Mailing Address - Fax:561-964-0035
Practice Address - Street 1:9314 FOREST HILL BLVD STE 204
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33411-6577
Practice Address - Country:US
Practice Address - Phone:561-213-4944
Practice Address - Fax:561-964-0035
Is Sole Proprietor?:No
Enumeration Date:2015-02-20
Last Update Date:2015-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1154532163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant