Provider Demographics
NPI:1386886752
Name:BLAKE, SHIRLEY (RNC)
Entity type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:
Last Name:BLAKE
Suffix:
Gender:F
Credentials:RNC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4331 THURMOND TANNER PARKWAY
Mailing Address - Street 2:
Mailing Address - City:FLOWERY BRANCH
Mailing Address - State:GA
Mailing Address - Zip Code:30542-7979
Mailing Address - Country:US
Mailing Address - Phone:678-513-5700
Mailing Address - Fax:
Practice Address - Street 1:3509 MABRY ROAD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30504-7979
Practice Address - Country:US
Practice Address - Phone:770-536-2310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-01
Last Update Date:2009-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN125274163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse