Provider Demographics
NPI:1467284398
Name:BLAKE, SHARON A
Entity type:Individual
Prefix:
First Name:SHARON
Middle Name:A
Last Name:BLAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHARON
Other - Middle Name:A
Other - Last Name:MONTPLAISIR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:ANDREA REESE
Mailing Address - Street 1:8 LOMBARDY ST
Mailing Address - Street 2:SUITE342
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07102
Mailing Address - Country:US
Mailing Address - Phone:201-285-9709
Mailing Address - Fax:
Practice Address - Street 1:22 SEYMOUR AVE
Practice Address - Street 2:3
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07108
Practice Address - Country:US
Practice Address - Phone:201-285-9709
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-19
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ0451157670171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor