Provider Demographics
NPI:1063213650
Name:SELLERS, BLAKE
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:SELLERS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1339 SW 181ST AVE
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33029-4904
Mailing Address - Country:US
Mailing Address - Phone:607-372-1789
Mailing Address - Fax:
Practice Address - Street 1:84 W SOUTH ST
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18766-0997
Practice Address - Country:US
Practice Address - Phone:607-372-1789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-20
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11038266363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health