Provider Demographics
NPI:1063879617
Name:BLAKE-DENNIS, SHALENE P (CRNA)
Entity type:Individual
Prefix:
First Name:SHALENE
Middle Name:P
Last Name:BLAKE-DENNIS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7700 W SUNRISE BLVD
Mailing Address - Street 2:PL-14-MAIL
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33322-4113
Mailing Address - Country:US
Mailing Address - Phone:954-838-2371
Mailing Address - Fax:954-851-1746
Practice Address - Street 1:13001 SOUTHERN BLVD
Practice Address - Street 2:
Practice Address - City:LOXAHATCHEE
Practice Address - State:FL
Practice Address - Zip Code:33470-9203
Practice Address - Country:US
Practice Address - Phone:561-798-1733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-26
Last Update Date:2017-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9203976163W00000X
FLARNP9203976367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse