Provider Demographics
NPI:1992905905
Name:BLAKE, KAREN E
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:E
Last Name:BLAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KAREN
Other - Middle Name:E
Other - Last Name:DEMILLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LVN
Mailing Address - Street 1:909 VZ COUNTY ROAD 2313
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:TX
Mailing Address - Zip Code:75103-4851
Mailing Address - Country:US
Mailing Address - Phone:903-848-4710
Mailing Address - Fax:903-848-9420
Practice Address - Street 1:909 VZ COUNTY ROAD 2313
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:TX
Practice Address - Zip Code:75103-4851
Practice Address - Country:US
Practice Address - Phone:903-848-4710
Practice Address - Fax:903-848-9420
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-19
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX741293163W00000X
TX112553164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1002581Medicaid