Provider Demographics
NPI:1780150060
Name:BLAKE, GREGORY ALEN JR (MSN, APRN, FNP-BC)
Entity type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:ALEN
Last Name:BLAKE
Suffix:JR
Gender:M
Credentials:MSN, APRN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1636 TUNIS DR
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:OH
Mailing Address - Zip Code:45030-2834
Mailing Address - Country:US
Mailing Address - Phone:513-265-3449
Mailing Address - Fax:
Practice Address - Street 1:1636 TUNIS DR
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:OH
Practice Address - Zip Code:45030-2834
Practice Address - Country:US
Practice Address - Phone:513-265-3449
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-15
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.023765363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily