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NPI Code Detail

MEDICARE: PENNY BLAKE APRN

MEDICARE: PENNY BLAKE APRN
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
1363LF0000XFamily Nurse PractitionerAP132551TX

General Provider Information

NPI Number : 1215489935
Entity Type Code : Individual
Provider Name (Legal Business Name) : PENNY BLAKE APRN
Provider Business Mailing Address
First Line : PO BOX 1022
Second Line :
City : WAYNESBORO
State : TN
Zip : 38485-1022
Country : US
Telephone Number : 931-722-2369
Fax Number :
Provider Business Practice Location Address
First Line : 1600 US HIGHWAY 79 S
Second Line :
City : HENDERSON
State : TX
Zip : 75654-4508
Country : US
Telephone Number : 903-717-3260
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/28/2016
Last Update Date : 08/07/2024

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Directions to “ PENNY BLAKE APRN” Practice Location

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