Provider Demographics
NPI:1043224272
Name:BLAKE, CHARLES BARTLETT (RN)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:BARTLETT
Last Name:BLAKE
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 N 36TH ST
Mailing Address - Street 2:
Mailing Address - City:NIXA
Mailing Address - State:MO
Mailing Address - Zip Code:65714-7560
Mailing Address - Country:US
Mailing Address - Phone:417-343-4202
Mailing Address - Fax:417-869-1521
Practice Address - Street 1:208 N 36TH ST
Practice Address - Street 2:
Practice Address - City:NIXA
Practice Address - State:MO
Practice Address - Zip Code:65714-7560
Practice Address - Country:US
Practice Address - Phone:417-343-4202
Practice Address - Fax:417-869-1521
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO088073163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse