Healthcare Provider Details

I. General information

NPI: 1194398818
Provider Name (Legal Business Name): BLAKE WRAY STANDIFER ARNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2021
Last Update Date: 10/05/2021
Certification Date: 10/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 LAUREL ST STE A250
DES MOINES IA
50314-3029
US

IV. Provider business mailing address

PO BOX 9170
DES MOINES IA
50306-9170
US

V. Phone/Fax

Practice location:
  • Phone: 515-235-5000
  • Fax: 515-288-6713
Mailing address:
  • Phone: 515-633-3600
  • Fax: 515-633-3838

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberH164471
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberH164471
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: