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General NPI Number Information
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NPI Number | 1649543042
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Entity Type | Individual
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Provider Name | TRACI LEIGH BLAKE DNP,ACNPC-AG, CRNFA
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Gender | Female
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Dates
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Enumeration Date | 02/15/2012
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Last Update Date | 05/01/2025
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Provider Practice Location Address
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Address Line | 8201 E RIVERSIDE BLVD
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City | ROCKFORD
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State | IL
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Zip | 61114-2300
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Country | US
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Telephone | 815-971-7000
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Fax |
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Provider Business Mailing Address
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Address Line | 2563 W CREEDY RD # 1
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City | BELOIT
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State | WI
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Zip | 53511-8707
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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 | 163WR0006X
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Taxonomy Name | Registered Nurse First Assistant
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License Number | 041336983
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 363LA2100X
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Taxonomy Name | Acute Care Nurse Practitioner
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License Number | 209032163
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License Number State | IL
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