Provider Demographics
NPI:1578262192
Name:COFFMAN, BLAKE (RN)
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:COFFMAN
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 1:64 PALMER DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-8029
Mailing Address - Country:US
Mailing Address - Phone:731-614-0728
Mailing Address - Fax:
Practice Address - Street 1:64 PALMER DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-8029
Practice Address - Country:US
Practice Address - Phone:731-614-0728
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-02
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN35606207P00000X, 207Q00000X, 207R00000X, 208000000X, 208100000X, 2085R0202X, 208600000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No208600000XAllopathic & Osteopathic PhysiciansSurgery