Provider Demographics
NPI:1770735912
Name:BLAKE, CANDANCE LUCHETTA (BA)
Entity type:Individual
Prefix:
First Name:CANDANCE
Middle Name:LUCHETTA
Last Name:BLAKE
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15251 PLEASANT VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:CENTER CITY
Mailing Address - State:MN
Mailing Address - Zip Code:55012-9640
Mailing Address - Country:US
Mailing Address - Phone:651-213-4494
Mailing Address - Fax:651-213-4411
Practice Address - Street 1:15251 PLEASANT VALLEY RD
Practice Address - Street 2:
Practice Address - City:CENTER CITY
Practice Address - State:MN
Practice Address - Zip Code:55012-9640
Practice Address - Country:US
Practice Address - Phone:651-213-4494
Practice Address - Fax:651-213-4411
Is Sole Proprietor?:No
Enumeration Date:2008-10-21
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program