Healthcare Provider Details

I. General information

NPI: 1548665136
Provider Name (Legal Business Name): BLAKE M WOODS DNP, APN, AGNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2014
Last Update Date: 12/01/2020
Certification Date: 12/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1203 W 10TH ST
METROPOLIS IL
62960-2433
US

IV. Provider business mailing address

503 W 19TH ST
METROPOLIS IL
62960-1104
US

V. Phone/Fax

Practice location:
  • Phone: 618-524-3795
  • Fax:
Mailing address:
  • Phone: 618-638-0208
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1102339
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041336078
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number3009061
License Number StateKY
# 4
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number209012171
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: