Provider Demographics
NPI:1053585638
Name:BLAKE, STEPHANIE MCCALLUM (MSN, NNP-BC)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:MCCALLUM
Last Name:BLAKE
Suffix:
Gender:F
Credentials:MSN, NNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 E CENTER ST APT 401
Mailing Address - Street 2:
Mailing Address - City:MEBANE
Mailing Address - State:NC
Mailing Address - Zip Code:27302-2577
Mailing Address - Country:US
Mailing Address - Phone:919-423-6885
Mailing Address - Fax:
Practice Address - Street 1:2301 ERWIN RD
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-4699
Practice Address - Country:US
Practice Address - Phone:919-681-5551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-15
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC930229363L00000X
NC122339363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner