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General NPI Number Information
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NPI Number | 1144710815
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Entity Type | Individual
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Provider Name | STEPHANIE BLAKE ATC/LAT
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Gender | Female
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Dates
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Enumeration Date | 05/17/2018
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Last Update Date | 05/17/2018
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Provider Practice Location Address
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Address Line | 60 W FULBRIGHT ST
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City | WALNUT RIDGE
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State | AR
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Zip | 72476-9000
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Country | US
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Telephone | 870-208-5631
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Fax |
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Provider Business Mailing Address
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Address Line | 211 FAIRGROUNDS RD
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City | HARRISBURG
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State | AR
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Zip | 72432-1306
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | AT701
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License Number State | AR
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