MEDICARE: LAQUITA 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	172V00000X	Community Health Worker
2	374J00000X	Doula

General Provider Information

NPI Number	:	1992465462
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAQUITA BLAKE

Provider Business Mailing Address
First Line	:	511 E 29TH ST
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23224-3537
Country	:	US
Telephone Number	:	804-618-0862
Fax Number	:

Provider Business Practice Location Address
First Line	:	511 E 29TH ST
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23224-3537
Country	:	US
Telephone Number	:	804-618-0862
Fax Number	:

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

Provider Enumeration Date	:	12/27/2021
Last Update Date	:	12/27/2021

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Directions to “ LAQUITA BLAKE ” Practice Location

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