Provider Demographics
NPI:1881499226
Name:BLAKE, TYANNA LEIGH (RT(R))
Entity type:Individual
Prefix:
First Name:TYANNA
Middle Name:LEIGH
Last Name:BLAKE
Suffix:
Gender:F
Credentials:RT(R)
Other - Prefix:
Other - First Name:TYANNA
Other - Middle Name:LEIGH
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10010 N 50TH AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85302-2419
Mailing Address - Country:US
Mailing Address - Phone:623-826-5388
Mailing Address - Fax:
Practice Address - Street 1:650 E INDIAN SCHOOL RD # RF
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-1839
Practice Address - Country:US
Practice Address - Phone:602-277-5551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-18
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZCRT0000104107247100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist