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General NPI Number Information
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NPI Number | 1194480335
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Entity Type | Individual
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Provider Name | DWAYNE BLAKE NP
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Gender | Male
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Dates
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Enumeration Date | 11/02/2021
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Last Update Date | 07/01/2025
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Provider Practice Location Address
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Address Line | 31 COVERT AVE # 1030
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City | FLORAL PARK
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State | NY
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Zip | 11001-3216
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Country | US
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Telephone | 516-402-0194
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Fax | 516-232-9534
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Provider Business Mailing Address
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Address Line | 31 COVERT AVE # 1030
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City | FLORAL PARK
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State | NY
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Zip | 11001-3216
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Country | US
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Telephone | 516-402-0194
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Fax | 518-933-2531
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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 | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 407104
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 348517
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License Number State | NY
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