1013978535 NPI number — AMY SUSAN BLAKE FNP-BC

Table of content: AMY SUSAN BLAKE FNP-BC (NPI 1013978535)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013978535 NPI number — AMY SUSAN BLAKE FNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLAKE
Provider First Name:
AMY
Provider Middle Name:
SUSAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP-BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GEMMILL
Provider Other First Name:
AMY
Provider Other Middle Name:
SUSAN
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
FNP-BC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1013978535
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/17/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
129 CAMBRIDGE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LANDENBERG
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19350-1304
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
302-757-0861
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
680 BLAIR MILL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HORSHAM
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19044-2223
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-304-6341
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/01/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  LG-0000384 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1013978535 , issued by the state of ( DE ) . This identifiers is of the category "MEDICAID".