Basic Information
| Provider Information | |||||||||
| NPI: | 1902878192 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLAKE | ||||||||
| FirstName: | STEDMOND | ||||||||
| MiddleName: | L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1060 GAFFNEY RD | ||||||||
| Address2: | COMMANDER,USA-MAEEAC-AK,ATTN:MCUC-MMD-QM | ||||||||
| City: | FT WAINWRIGHT | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997035001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9073535418 | ||||||||
| FaxNumber: | 9073534845 | ||||||||
| Practice Location | |||||||||
| Address1: | 1060 GAFFNEY RD | ||||||||
| Address2: | COMMANDER,USA-MAEEAC-AK,ATTN:MCUC-MMD-QM | ||||||||
| City: | FT WAINWRIGHT | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997035001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9073535418 | ||||||||
| FaxNumber: | 9073534845 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | P5585 | AK | Y | Nursing Service Providers | Licensed Practical Nurse |
No ID Information.