Provider Demographics
NPI:1528506524
Name:BLAKE, KAREN
Entity type:Individual
Prefix:
First Name:KAREN
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:PO BOX 2606
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31521-2606
Mailing Address - Country:US
Mailing Address - Phone:912-289-7828
Mailing Address - Fax:912-289-9378
Practice Address - Street 1:2606 COAST ST.
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31521-2606
Practice Address - Country:US
Practice Address - Phone:912-289-7828
Practice Address - Fax:912-289-9378
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-09
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA036870799343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)