Healthcare Provider Details

I. General information

NPI: 1194480335
Provider Name (Legal Business Name): DWAYNE BLAKE NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2021
Last Update Date: 07/01/2025
Certification Date: 07/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 COVERT AVE # 1030
FLORAL PARK NY
11001-3216
US

IV. Provider business mailing address

31 COVERT AVE # 1030
FLORAL PARK NY
11001-3216
US

V. Phone/Fax

Practice location:
  • Phone: 516-402-0194
  • Fax: 516-232-9534
Mailing address:
  • Phone: 516-402-0194
  • Fax: 518-933-2531

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number348517
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number407104
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: