Healthcare Provider Details

I. General information

NPI: 1548026495
Provider Name (Legal Business Name): PATRENA MECHELL BLAKE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2024
Last Update Date: 02/27/2024
Certification Date: 02/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 WASHINGTON ST
MONROE LA
71201-6714
US

IV. Provider business mailing address

803 S 14TH ST
MONROE LA
71202-2425
US

V. Phone/Fax

Practice location:
  • Phone: 318-557-7944
  • Fax:
Mailing address:
  • Phone: 318-547-3779
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: