Provider Demographics
NPI:1902314289
Name:LAWRENCE, BLAKE
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:LAWRENCE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:634 S 1870 W
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84059-4963
Mailing Address - Country:US
Mailing Address - Phone:208-316-9539
Mailing Address - Fax:
Practice Address - Street 1:2100 W PLEASANT GROVE BLVD STE 270
Practice Address - Street 2:
Practice Address - City:PLEASANT GROVE
Practice Address - State:UT
Practice Address - Zip Code:84062-3375
Practice Address - Country:US
Practice Address - Phone:208-316-9539
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-20
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12078815-4405363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty