Provider Demographics
NPI:1801509161
Name:BLAKE, DREMA GALE
Entity type:Individual
Prefix:
First Name:DREMA
Middle Name:GALE
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 1:12259 JERRY WEST HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:SARAH ANN
Mailing Address - State:WV
Mailing Address - Zip Code:25644
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12259 JERRY WEST HIGHWAY
Practice Address - Street 2:
Practice Address - City:SARAH ANN
Practice Address - State:WV
Practice Address - Zip Code:25644
Practice Address - Country:US
Practice Address - Phone:304-733-1094
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-03
Last Update Date:2023-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant