Provider Demographics
NPI:1902787997
Name:BLAKE, OLIVIA KEELIN (CRNP)
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:KEELIN
Last Name:BLAKE
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:169 N PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18701-3603
Mailing Address - Country:US
Mailing Address - Phone:570-346-8147
Mailing Address - Fax:570-230-0013
Practice Address - Street 1:169 N PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18701-3603
Practice Address - Country:US
Practice Address - Phone:570-346-8147
Practice Address - Fax:570-230-0013
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-08
Last Update Date:2025-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP033283363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner