Healthcare Provider Details

I. General information

NPI: 1861354706
Provider Name (Legal Business Name): SHAMEKA BLAKE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2025
Last Update Date: 12/01/2025
Certification Date: 11/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43 DELORIS MADISON DR
MIDWAY FL
32343-2250
US

IV. Provider business mailing address

43 DELORIS MADISON DR
MIDWAY FL
32343-2250
US

V. Phone/Fax

Practice location:
  • Phone: 850-694-5585
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number9542974
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: