MEDICARE: ELIZABETH ANN BLAKE PMHNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	11043962	FL

General Provider Information

NPI Number	:	1619832508
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIZABETH ANN BLAKE PMHNP-BC

Provider Business Mailing Address
First Line	:	1701 N 41ST AVE FL 33021
Second Line	:
City	:	HOLLYWOOD
State	:	FL
Zip	:	33021-4216
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1701 N 41ST AVE FL 33021
Second Line	:
City	:	HOLLYWOOD
State	:	FL
Zip	:	33021-4216
Country	:	US
Telephone Number	:	954-881-0668
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/22/2025
Last Update Date	:	12/22/2025

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