MEDICARE: CAROL BLAKE, MSN, RN, CNS, CRNFA, CNOR, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	364SP2800X	Perioperative Clinical Nurse Specialist	RN036821	AZ

General Provider Information

NPI Number	:	1073678785
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAROL BLAKE, MSN, RN, CNS, CRNFA, CNOR, PC

Provider Business Mailing Address
First Line	:	4091 E NISBET RD
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85032-4767
Country	:	US
Telephone Number	:	602-971-8588
Fax Number	:	602-971-3887

Provider Business Practice Location Address
First Line	:	4091 E NISBET RD
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85032-4767
Country	:	US
Telephone Number	:	602-971-8588
Fax Number	:	602-971-3887

Authorized Official
Title or Position	:	PRESIDENT
Name	:	CAROL BLAKE
Credential	:	CNS, CRNFA
Telephone Number	:	602-971-8599

Provider Enumeration Date	:	12/22/2006
Last Update Date	:	08/22/2020

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