Healthcare Provider Details

I. General information

NPI: 1881472371
Provider Name (Legal Business Name): LARA BLAKE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2023
Last Update Date: 09/18/2023
Certification Date: 09/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

845 S MADISON ST
TUPELO MS
38801-4905
US

IV. Provider business mailing address

2056 NEW CHAPEL RD
NETTLETON MS
38858-8257
US

V. Phone/Fax

Practice location:
  • Phone: 662-377-3000
  • Fax:
Mailing address:
  • Phone: 662-538-8753
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number906281
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: