Provider Demographics
NPI:1144053596
Name:BLAKE, AMANDA PUCKETT (CNM)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:PUCKETT
Last Name:BLAKE
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:LORAINE
Other - Last Name:PUCKETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:42 SHOALS TRL
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:GA
Mailing Address - Zip Code:30132-6045
Mailing Address - Country:US
Mailing Address - Phone:404-275-0054
Mailing Address - Fax:
Practice Address - Street 1:1791 MULKEY RD STE 200
Practice Address - Street 2:
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-1124
Practice Address - Country:US
Practice Address - Phone:770-732-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-21
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN173764176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife