Provider Demographics
NPI:1649876046
Name:BLAKE, BRIAN G (APRN, FNP-BC, RN)
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:G
Last Name:BLAKE
Suffix:
Gender:M
Credentials:APRN, FNP-BC, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15604 ROB ROY DR
Mailing Address - Street 2:
Mailing Address - City:OAK FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60452-2738
Mailing Address - Country:US
Mailing Address - Phone:773-771-8197
Mailing Address - Fax:
Practice Address - Street 1:8135 CALUMET AVE
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-1701
Practice Address - Country:US
Practice Address - Phone:219-513-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-10
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.022503363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily