Healthcare Provider Details

I. General information

NPI: 1780881326
Provider Name (Legal Business Name): SHERRY LEE BLAKE OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SHERRY LEE HOWARD OTR

II. Dates (important events)

Enumeration Date: 06/28/2007
Last Update Date: 11/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12840 83RD AVE
ROSELAND FL
32957
US

IV. Provider business mailing address

PO BOX 1175
ROSELAND FL
32957-1175
US

V. Phone/Fax

Practice location:
  • Phone: 772-532-0853
  • Fax: 772-571-6190
Mailing address:
  • Phone: 772-532-0853
  • Fax: 772-571-6190

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberOT 2648
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: