Healthcare Provider Details

I. General information

NPI: 1073678785
Provider Name (Legal Business Name): CAROL BLAKE, MSN, RN, CNS, CRNFA, CNOR, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4091 E NISBET RD
PHOENIX AZ
85032-4767
US

IV. Provider business mailing address

4091 E NISBET RD
PHOENIX AZ
85032-4767
US

V. Phone/Fax

Practice location:
  • Phone: 602-971-8588
  • Fax: 602-971-3887
Mailing address:
  • Phone: 602-971-8588
  • Fax: 602-971-3887

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP2800X
TaxonomyPerioperative Clinical Nurse Specialist
License NumberRN036821
License Number StateAZ

VIII. Authorized Official

Name: CAROL BLAKE
Title or Position: PRESIDENT
Credential: CNS, CRNFA
Phone: 602-971-8599