Provider Demographics
NPI:1982442349
Name:BLAKE, LAUREN PAYTON
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:PAYTON
Last Name:BLAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 FOX RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:ELDRIDGE
Mailing Address - State:IA
Mailing Address - Zip Code:52748-2306
Mailing Address - Country:US
Mailing Address - Phone:564-549-0736
Mailing Address - Fax:
Practice Address - Street 1:1320 W LOMBARD ST
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52804-2029
Practice Address - Country:US
Practice Address - Phone:563-333-5827
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-18
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program