Provider Demographics
NPI:1902878192
Name:BLAKE, STEDMOND L
Entity Type:Individual
Prefix:
First Name:STEDMOND
Middle Name:L
Last Name:BLAKE
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 1:1060 GAFFNEY RD
Mailing Address - Street 2:COMMANDER,USA-MAEEAC-AK,ATTN:MCUC-MMD-QM
Mailing Address - City:FT WAINWRIGHT
Mailing Address - State:AK
Mailing Address - Zip Code:99703-5001
Mailing Address - Country:US
Mailing Address - Phone:907-353-5418
Mailing Address - Fax:907-353-4845
Practice Address - Street 1:1060 GAFFNEY RD
Practice Address - Street 2:COMMANDER,USA-MAEEAC-AK,ATTN:MCUC-MMD-QM
Practice Address - City:FT WAINWRIGHT
Practice Address - State:AK
Practice Address - Zip Code:99703-5001
Practice Address - Country:US
Practice Address - Phone:907-353-5418
Practice Address - Fax:907-353-4845
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKP5585164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse