Healthcare Provider Details

I. General information

NPI: 1649876046
Provider Name (Legal Business Name): BRIAN G BLAKE APRN, FNP-BC, RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/10/2020
Last Update Date: 02/08/2021
Certification Date: 02/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8135 CALUMET AVE
MUNSTER IN
46321-1701
US

IV. Provider business mailing address

15604 ROB ROY DR
OAK FOREST IL
60452-2738
US

V. Phone/Fax

Practice location:
  • Phone: 219-513-2000
  • Fax:
Mailing address:
  • Phone: 773-771-8197
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.022503
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: