Provider Demographics
NPI:1598548463
Name:BLAKE, ANGELA LYNN (DNP)
Entity type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:LYNN
Last Name:BLAKE
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:LYNN
Other - Last Name:ARAGON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1387
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-1387
Mailing Address - Country:US
Mailing Address - Phone:208-415-0299
Mailing Address - Fax:
Practice Address - Street 1:16760 N HIGHWAY 41
Practice Address - Street 2:
Practice Address - City:RATHDRUM
Practice Address - State:ID
Practice Address - Zip Code:83858-8715
Practice Address - Country:US
Practice Address - Phone:208-687-5627
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-15
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID747465363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily