Provider Demographics
NPI:1114813706
Name:BLAKE, ANGELICA MARIE (FNP)
Entity type:Individual
Prefix:
First Name:ANGELICA
Middle Name:MARIE
Last Name:BLAKE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41701 TISCHER AVE
Mailing Address - Street 2:
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-8504
Mailing Address - Country:US
Mailing Address - Phone:907-690-3196
Mailing Address - Fax:
Practice Address - Street 1:41701 TISCHER AVE
Practice Address - Street 2:
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-8504
Practice Address - Country:US
Practice Address - Phone:907-690-3196
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-18
Last Update Date:2025-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK239396363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily