Healthcare Provider Details

I. General information

NPI: 1053264689
Provider Name (Legal Business Name): OLIVIA BLAKE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2026
Last Update Date: 02/16/2026
Certification Date: 02/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 I ST NW
WASHINGTON DC
20052-0086
US

IV. Provider business mailing address

1205 TOWN SIDE DR
APEX NC
27502-6803
US

V. Phone/Fax

Practice location:
  • Phone: 202-994-1000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: