Healthcare Provider Details

I. General information

NPI: 1255990719
Provider Name (Legal Business Name): BRIA NIKOLE WILLIAMS BLAKE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2019
Last Update Date: 08/31/2023
Certification Date: 08/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1918 RANDOLPH RD STE 670
CHARLOTTE NC
28207-1119
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 704-384-1620
  • Fax: 704-384-1626
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberLL82792
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number2023-01746
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: