Provider Demographics
NPI:1912507336
Name:MCGAREL-TITTLE, BLAKE AUGUST (CNM)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:AUGUST
Last Name:MCGAREL-TITTLE
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:BLAKE
Other - Middle Name:AUGUST
Other - Last Name:MCGAREL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNM
Mailing Address - Street 1:3707 STATE PARK RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29609-6848
Mailing Address - Country:US
Mailing Address - Phone:928-460-1139
Mailing Address - Fax:
Practice Address - Street 1:3707 STATE PARK RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29609-6848
Practice Address - Country:US
Practice Address - Phone:928-460-1139
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-26
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC24517367A00000X
176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCQ706873365OtherMEDICARE PIN
SCMW0283Medicaid