Provider Demographics
NPI:1366560773
Name:BLAKE, CATHERINE L (APN CNP)
Entity type:Individual
Prefix:MRS
First Name:CATHERINE
Middle Name:L
Last Name:BLAKE
Suffix:
Gender:F
Credentials:APN CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1615 MACARTHUR DR
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-6153
Mailing Address - Country:US
Mailing Address - Phone:815-226-8084
Mailing Address - Fax:
Practice Address - Street 1:1848 DAIMLER RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61112-1019
Practice Address - Country:US
Practice Address - Phone:815-229-2500
Practice Address - Fax:815-316-1881
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health