Individual
LARA BLAKE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
845 S MADISON ST, TUPELO, MS 38801-4905
(662) 377-3000
Mailing address
2056 NEW CHAPEL RD, NETTLETON, MS 38858-8257
(662) 538-8753
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
906281
MS
Other
Enumeration date
09/18/2023
Last updated
09/18/2023
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