Provider Demographics
NPI:1659255321
Name:HOUSEWORTH, BLAKE (FNP-C)
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:HOUSEWORTH
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:628 RIVERVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32714-7428
Mailing Address - Country:US
Mailing Address - Phone:386-882-5892
Mailing Address - Fax:
Practice Address - Street 1:831 S STATE ROAD 434
Practice Address - Street 2:
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32714-3502
Practice Address - Country:US
Practice Address - Phone:407-587-8600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-04
Last Update Date:2025-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11037768363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily