Provider Demographics
NPI:1548665136
Name:WOODS, BLAKE M (DNP, APN, AGNP-C)
Entity type:Individual
Prefix:MR
First Name:BLAKE
Middle Name:M
Last Name:WOODS
Suffix:
Gender:M
Credentials:DNP, APN, AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 W 19TH ST
Mailing Address - Street 2:
Mailing Address - City:METROPOLIS
Mailing Address - State:IL
Mailing Address - Zip Code:62960-1104
Mailing Address - Country:US
Mailing Address - Phone:618-638-0208
Mailing Address - Fax:
Practice Address - Street 1:1203 W 10TH ST
Practice Address - Street 2:
Practice Address - City:METROPOLIS
Practice Address - State:IL
Practice Address - Zip Code:62960-2433
Practice Address - Country:US
Practice Address - Phone:618-524-3795
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-26
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1102339163W00000X
IL041336078163W00000X
KY3009061363LP2300X
IL209012171363LP2300X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No163W00000XNursing Service ProvidersRegistered Nurse