Provider Demographics
NPI:1164780177
Name:BLAKE, MARY L (ANP-C)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:L
Last Name:BLAKE
Suffix:
Gender:F
Credentials:ANP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2936 CALDWELL RIDGE PKWY
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28213-5888
Mailing Address - Country:US
Mailing Address - Phone:704-578-8041
Mailing Address - Fax:
Practice Address - Street 1:2936 CALDWELL RIDGE PKWY
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28213-5888
Practice Address - Country:US
Practice Address - Phone:704-578-8041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-26
Last Update Date:2024-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5005601363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health