Healthcare Provider Details

I. General information

NPI: 1881061372
Provider Name (Legal Business Name): TANYA BLAKE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2015
Last Update Date: 05/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5719 RIORDAN WAY
ORLANDO FL
32808-2433
US

IV. Provider business mailing address

5719 RIORDAN WAY
ORLANDO FL
32808-2433
US

V. Phone/Fax

Practice location:
  • Phone: 407-844-1782
  • Fax: 321-800-6803
Mailing address:
  • Phone: 407-844-1782
  • Fax: 321-800-6803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License NumberCNA283280
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: