Provider Demographics
NPI:1881061372
Name:BLAKE, TANYA
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:
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 1:5719 RIORDAN WAY
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32808-2433
Mailing Address - Country:US
Mailing Address - Phone:407-844-1782
Mailing Address - Fax:321-800-6803
Practice Address - Street 1:5719 RIORDAN WAY
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32808-2433
Practice Address - Country:US
Practice Address - Phone:407-844-1782
Practice Address - Fax:321-800-6803
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-31
Last Update Date:2016-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCNA283280376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide