Provider Demographics
NPI:1174637748
Name:BLAKE, ANDREA (ARNP)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:BLAKE
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1475
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50306-1475
Mailing Address - Country:US
Mailing Address - Phone:515-643-4973
Mailing Address - Fax:
Practice Address - Street 1:1111 6TH AVE
Practice Address - Street 2:EAST TOWER SUITE A100
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50314-2610
Practice Address - Country:US
Practice Address - Phone:515-358-0011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2008-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR162244363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0485813Medicaid
IA0485813Medicaid
IAI16796Medicare ID - Type Unspecified