Healthcare Provider Details

I. General information

NPI: 1487320495
Provider Name (Legal Business Name): LETTRICE TAYLOR-BLAKE NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2021
Last Update Date: 10/04/2022
Certification Date: 10/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4160 LITTLE YORK RD STE 20
DAYTON OH
45414-5803
US

IV. Provider business mailing address

306 SHADY TREE CT
ENGLEWOOD OH
45315-9652
US

V. Phone/Fax

Practice location:
  • Phone: 937-454-9527
  • Fax: 937-454-9532
Mailing address:
  • Phone: 937-533-9963
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.0029516
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: