Provider Demographics
NPI:1568206340
Name:BLAKE, TIANNA RAE (FNP-BC)
Entity type:Individual
Prefix:
First Name:TIANNA
Middle Name:RAE
Last Name:BLAKE
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 HENRY ST
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12203-5918
Mailing Address - Country:US
Mailing Address - Phone:607-437-2227
Mailing Address - Fax:
Practice Address - Street 1:460 ANDES RD
Practice Address - Street 2:
Practice Address - City:DELHI
Practice Address - State:NY
Practice Address - Zip Code:13753-7407
Practice Address - Country:US
Practice Address - Phone:607-746-0550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-25
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF354471-01363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily