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General NPI Number Information
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NPI Number | 1598548463
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Entity Type | Individual
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Provider Name | ANGELA LYNN BLAKE DNP
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Gender | Female
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Dates
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Enumeration Date | 08/15/2023
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Last Update Date | 12/19/2024
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Provider Practice Location Address
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Address Line | 16760 N HIGHWAY 41
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City | RATHDRUM
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State | ID
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Zip | 83858-8715
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Country | US
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Telephone | 208-687-5627
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1387
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City | HAYDEN
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State | ID
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Zip | 83835-1387
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Country | US
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Telephone | 208-415-0299
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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 | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 747465
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 747465
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License Number State | ID
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