Provider Demographics
NPI:1174941447
Name:BLAKE, TRACEY (RN, IBCLC)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:BLAKE
Suffix:
Gender:F
Credentials:RN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 N MARR RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:IN
Mailing Address - Zip Code:47201-5505
Mailing Address - Country:US
Mailing Address - Phone:812-376-9219
Mailing Address - Fax:
Practice Address - Street 1:1120 N MARR RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47201-5505
Practice Address - Country:US
Practice Address - Phone:812-376-9219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-02
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN11136128163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant