Provider Demographics
NPI:1104545003
Name:BLAKE, CARLA MARIE
Entity type:Individual
Prefix:
First Name:CARLA
Middle Name:MARIE
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 1:311 E PIKE ST
Mailing Address - Street 2:
Mailing Address - City:CLARKSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26301-2118
Mailing Address - Country:US
Mailing Address - Phone:304-627-9754
Mailing Address - Fax:
Practice Address - Street 1:311 E PIKE ST
Practice Address - Street 2:
Practice Address - City:CLARKSBURG
Practice Address - State:WV
Practice Address - Zip Code:26301-2118
Practice Address - Country:US
Practice Address - Phone:304-627-9754
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-24
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant