Provider Demographics
NPI:1528532272
Name:BLAKE-RAUT, MARISA KRISTINE (FNP-C, ENP-C)
Entity type:Individual
Prefix:MRS
First Name:MARISA
Middle Name:KRISTINE
Last Name:BLAKE-RAUT
Suffix:
Gender:F
Credentials:FNP-C, ENP-C
Other - Prefix:
Other - First Name:MARISA
Other - Middle Name:KRISTINE
Other - Last Name:JAHNKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:PO BOX 1200
Mailing Address - Street 2:
Mailing Address - City:PLEASANT GROVE
Mailing Address - State:UT
Mailing Address - Zip Code:84062-1200
Mailing Address - Country:US
Mailing Address - Phone:800-640-3451
Mailing Address - Fax:
Practice Address - Street 1:2480 WINDY HILL RD SE STE 405
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-8658
Practice Address - Country:US
Practice Address - Phone:800-640-3451
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-16
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN193648363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARN193648OtherSTATE LICENSE