Provider Demographics
NPI:1003167933
Name:BLYTHE, JEAN FAIRCHILD (PA)
Entity Type:Individual
Prefix:MRS
First Name:JEAN
Middle Name:FAIRCHILD
Last Name:BLYTHE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5979 VINELAND RD STE 101
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32819-7860
Mailing Address - Country:US
Mailing Address - Phone:407-355-3120
Mailing Address - Fax:407-355-3119
Practice Address - Street 1:5979 VINELAND RD STE 101
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-7860
Practice Address - Country:US
Practice Address - Phone:407-355-3120
Practice Address - Fax:407-355-3119
Is Sole Proprietor?:No
Enumeration Date:2012-10-02
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY25402363A00000X
FLPAT 9106844363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant