Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2081S0010X | Sports Medicine | PTA24202 | FL |
Y | 213ES0000X | Sports Medicine | PTA24202 | FL |
NPI | 1376903039 |
---|---|
Provider Name | Emily A Blake |
First Address | Jacksonville, FL 32216-8066 |
Second Address | Jacksonville, FL 32204-4712 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/02/2016 |
Last Update Date | 26/09/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
PT24202 | STATE LICENSE (01) | FL |