Healthcare Provider Details

I. General information

NPI: 1649018847
Provider Name (Legal Business Name): ABIGAIL M BLAKE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2024
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL CENTER DR
LEBANON NH
03756-0001
US

IV. Provider business mailing address

PO BOX 810
HANOVER NH
03755-0810
US

V. Phone/Fax

Practice location:
  • Phone: 603-650-5000
  • Fax: 603-640-1228
Mailing address:
  • Phone: 603-308-1472
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number111923-23
License Number StateNH
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberF311792
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberEL31332
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: