Provider Demographics
NPI:1962888297
Name:BLAKE, WANDA
Entity type:Individual
Prefix:
First Name:WANDA
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 1:4300 ROSEMEADE PKWY APT 812
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75287-2921
Mailing Address - Country:US
Mailing Address - Phone:214-283-0892
Mailing Address - Fax:
Practice Address - Street 1:4300 ROSEMEADE PKWY APT 812
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75287-2921
Practice Address - Country:US
Practice Address - Phone:214-283-0892
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-10
Last Update Date:2015-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX626602278G1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2278G1100XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, CertifiedGeneral Care