Healthcare Provider Details

I. General information

NPI: 1861463994
Provider Name (Legal Business Name): CYNTHIA J. BLAKE APRN,BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2006
Last Update Date: 04/14/2021
Certification Date: 04/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 MACINNES DR
HOUGHTON MI
49931-1144
US

IV. Provider business mailing address

301 EXPLORER ST
GWINN MI
49841-2813
US

V. Phone/Fax

Practice location:
  • Phone: 906-483-1860
  • Fax: 906-483-1270
Mailing address:
  • Phone: 906-346-4924
  • Fax: 906-346-6474

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP008734
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: