Healthcare Provider Details

I. General information

NPI: 1225089857
Provider Name (Legal Business Name): ANNE B BLAKE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 02/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 DEWITT DR
LUGOFF SC
29078-9069
US

IV. Provider business mailing address

PO BOX 1259
CAMDEN SC
29021-1259
US

V. Phone/Fax

Practice location:
  • Phone: 803-438-7566
  • Fax: 803-438-4371
Mailing address:
  • Phone: 803-713-8350
  • Fax: 803-713-8433

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1450
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: