Healthcare Provider Details

I. General information

NPI: 1144187030
Provider Name (Legal Business Name): KENYA ALICIA BLAKE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2026
Last Update Date: 05/01/2026
Certification Date: 05/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1037 S STATE ROAD 7 STE 113
WELLINGTON FL
33414-6139
US

IV. Provider business mailing address

425 W COLONIAL DR STE 303
ORLANDO FL
32804-6863
US

V. Phone/Fax

Practice location:
  • Phone: 561-798-3030
  • Fax: 833-450-4577
Mailing address:
  • Phone: 833-702-8383
  • Fax: 689-304-0303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11044595
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number11044595
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: