Provider Demographics
NPI:1114928439
Name:BLALOCK, MISTY HALLONQUIST (NP)
Entity Type:Individual
Prefix:DR
First Name:MISTY
Middle Name:HALLONQUIST
Last Name:BLALOCK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:DR
Other - First Name:MISTY
Other - Middle Name:H
Other - Last Name:MORRISSEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:200 CORPORATE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-3870
Mailing Address - Country:US
Mailing Address - Phone:800-893-9698
Mailing Address - Fax:
Practice Address - Street 1:1304 LINDA DR
Practice Address - Street 2:
Practice Address - City:DAINGERFIELD
Practice Address - State:TX
Practice Address - Zip Code:75638-2130
Practice Address - Country:US
Practice Address - Phone:430-226-5110
Practice Address - Fax:430-226-5111
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX651612363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
12008144OtherCAQH