MEDICARE: DAWN M BLAKE

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	374U00000X	Home Health Aide

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2609878	OTHER	OH	INDEPENDANT PROVIDER NUMB

General Provider Information

NPI Number	:	1437371077
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAWN M BLAKE

Provider Business Mailing Address
First Line	:	229 HIGH ST
Second Line	:
City	:	ROSEVILLE
State	:	OH
Zip	:	43777-1113
Country	:	US
Telephone Number	:	740-697-0077
Fax Number	:

Provider Business Practice Location Address
First Line	:	100 1/2 OLD RAINER ROAD
Second Line	:
City	:	ROSEVILLE
State	:	OH
Zip	:	43777
Country	:	US
Telephone Number	:	740-697-0687
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/03/2007
Last Update Date	:	07/08/2007

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