Provider Demographics
NPI:1831168558
Name:BENNETT-BLAKE, DESREEN E (ARNP)
Entity type:Individual
Prefix:
First Name:DESREEN
Middle Name:E
Last Name:BENNETT-BLAKE
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7205 S GEORGE BLVD
Mailing Address - Street 2:
Mailing Address - City:SEBRING
Mailing Address - State:FL
Mailing Address - Zip Code:33875-5847
Mailing Address - Country:US
Mailing Address - Phone:863-386-6040
Mailing Address - Fax:863-386-6048
Practice Address - Street 1:7205 S GEORGE BLVD
Practice Address - Street 2:
Practice Address - City:SEBRING
Practice Address - State:FL
Practice Address - Zip Code:33875-5847
Practice Address - Country:US
Practice Address - Phone:863-386-6040
Practice Address - Fax:863-386-6048
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2008-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2036402363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL301858500Medicaid
FLARNP2036402OtherARNP LICENSE