Provider Demographics
NPI:1780881326
Name:BLAKE, SHERRY LEE (OTR)
Entity type:Individual
Prefix:
First Name:SHERRY
Middle Name:LEE
Last Name:BLAKE
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:SHERRY
Other - Middle Name:LEE
Other - Last Name:HOWARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR
Mailing Address - Street 1:PO BOX 1175
Mailing Address - Street 2:
Mailing Address - City:ROSELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32957-1175
Mailing Address - Country:US
Mailing Address - Phone:772-532-0853
Mailing Address - Fax:772-571-6190
Practice Address - Street 1:12840 83RD AVE
Practice Address - Street 2:
Practice Address - City:ROSELAND
Practice Address - State:FL
Practice Address - Zip Code:32957
Practice Address - Country:US
Practice Address - Phone:772-532-0853
Practice Address - Fax:772-571-6190
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-28
Last Update Date:2012-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT 2648174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL006673400Medicaid
FL006673400Medicaid