Healthcare Provider Details

I. General information

NPI: 1508018896
Provider Name (Legal Business Name): JILL ANN BLAKE FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2008
Last Update Date: 10/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3771 ROBERT C. BYRD DRIVE
BECKLEY WV
25801
US

IV. Provider business mailing address

PO BOX 82 109 DUFFY DRIVE
CRAB ORCHARD WV
25827-0082
US

V. Phone/Fax

Practice location:
  • Phone: 304-255-5710
  • Fax: 304-255-5702
Mailing address:
  • Phone: 304-253-7408
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number45615
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: