Provider Demographics
NPI:1083018063
Name:BLAYLOCK, LEISHA MONETTE (FNP-C)
Entity Type:Individual
Prefix:
First Name:LEISHA
Middle Name:MONETTE
Last Name:BLAYLOCK
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2078
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:TX
Mailing Address - Zip Code:76234
Mailing Address - Country:US
Mailing Address - Phone:940-683-2338
Mailing Address - Fax:940-683-2394
Practice Address - Street 1:2202 US HIGHWAY 380
Practice Address - Street 2:SUITE 112
Practice Address - City:BRIDGEPORT
Practice Address - State:TX
Practice Address - Zip Code:76426-2176
Practice Address - Country:US
Practice Address - Phone:940-683-2338
Practice Address - Fax:940-683-2394
Is Sole Proprietor?:No
Enumeration Date:2014-10-20
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP126686363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8397NMOtherBCBS
TX342225501Medicaid
TX8397NMOtherBCBS