Provider Demographics
NPI:1215808076
Name:BLAKE, DOMINIQUE
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
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 1:514 LOVELL AVE APT 7
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55113-4654
Mailing Address - Country:US
Mailing Address - Phone:651-315-3480
Mailing Address - Fax:
Practice Address - Street 1:514 LOVELL AVE APT 7
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-4654
Practice Address - Country:US
Practice Address - Phone:651-315-3480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-15
Last Update Date:2025-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide