Provider Demographics
NPI:1811306418
Name:BLAKE, KIMBERLY (AAS/CCMA)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:BLAKE
Suffix:
Gender:F
Credentials:AAS/CCMA
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:DAWN
Other - Last Name:CANTWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6350 W ANDREW JOHNSON HWY
Mailing Address - Street 2:DEPARTMENT 100
Mailing Address - City:TALBOTT
Mailing Address - State:TN
Mailing Address - Zip Code:37877-8605
Mailing Address - Country:US
Mailing Address - Phone:800-355-3565
Mailing Address - Fax:423-714-2355
Practice Address - Street 1:815 W 5TH NORTH ST
Practice Address - Street 2:
Practice Address - City:MORRISTOWN
Practice Address - State:TN
Practice Address - Zip Code:37814-3810
Practice Address - Country:US
Practice Address - Phone:423-586-5032
Practice Address - Fax:423-581-8473
Is Sole Proprietor?:No
Enumeration Date:2014-08-07
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other