Provider Demographics
NPI:1528794492
Name:BLAKE, COURTNEY L (FNP)
Entity type:Individual
Prefix:MRS
First Name:COURTNEY
Middle Name:L
Last Name:BLAKE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:L
Other - Last Name:BURROUGHS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:520 MARY ST STE 520
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47710-1682
Mailing Address - Country:US
Mailing Address - Phone:812-424-8231
Mailing Address - Fax:812-435-8794
Practice Address - Street 1:520 MARY ST STE 520
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47710-1682
Practice Address - Country:US
Practice Address - Phone:812-424-8231
Practice Address - Fax:812-435-8794
Is Sole Proprietor?:No
Enumeration Date:2022-07-25
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71012945A363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN71012945COtherCSR
IN300066603Medicaid
IN1102619435OtherANTHEM BCBS
KY7100861190Medicaid
IN71012945AOtherIN - LICENSE