MEDICARE: MRS. DAYNA BLAKE FNP- BC

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	363LP2300X	Primary Care Nurse Practitioner	225438	AZ

General Provider Information

NPI Number	:	1548825789
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. DAYNA BLAKE FNP- BC

Provider Business Mailing Address
First Line	:	PO BOX 10837
Second Line	:
City	:	FORT MOHAVE
State	:	AZ
Zip	:	86427-0837
Country	:	US
Telephone Number	:	928-201-8289
Fax Number	:	913-222-1782

Provider Business Practice Location Address
First Line	:	5221 HWY 95 STE 13
Second Line	:
City	:	FORT MOHAVE
State	:	AZ
Zip	:	86426-9244
Country	:	US
Telephone Number	:	928-201-8289
Fax Number	:	913-222-1782

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

Provider Enumeration Date	:	05/02/2019
Last Update Date	:	01/27/2026

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