Provider Demographics
NPI:1932966603
Name:BLAKE, CYNTHIA GAIL
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:GAIL
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 1:2825 LEDO RD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31707-1363
Mailing Address - Country:US
Mailing Address - Phone:229-883-6432
Mailing Address - Fax:229-883-9795
Practice Address - Street 1:2825 LEDO RD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31707-1363
Practice Address - Country:US
Practice Address - Phone:229-883-6432
Practice Address - Fax:229-883-9795
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-29
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALDO0001691156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician