Provider Demographics
NPI:1881466134
Name:MATHENY, BLAKE ELLIOTT (BSN)
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:ELLIOTT
Last Name:MATHENY
Suffix:
Gender:M
Credentials:BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8624 WALNUT AVE
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32534-3667
Mailing Address - Country:US
Mailing Address - Phone:850-602-0123
Mailing Address - Fax:
Practice Address - Street 1:8624 WALNUT AVE
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32534-3667
Practice Address - Country:US
Practice Address - Phone:850-602-0123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-30
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9513687163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse