Healthcare Provider Details

I. General information

NPI: 1831718725
Provider Name (Legal Business Name): TRUDY-ANN BLAKE LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2020
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 CENTER PL
TEANECK NJ
07666-1626
US

IV. Provider business mailing address

550 CENTER PL
TEANECK NJ
07666-1626
US

V. Phone/Fax

Practice location:
  • Phone: 201-212-1787
  • Fax:
Mailing address:
  • Phone: 201-212-1787
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberPN5232348
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: