Provider Demographics
NPI:1285019711
Name:BLAYLOCK, KRISTA
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:
Last Name:BLAYLOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 S PRESTON ST
Mailing Address - Street 2:
Mailing Address - City:RANSON
Mailing Address - State:WV
Mailing Address - Zip Code:25438-1631
Mailing Address - Country:US
Mailing Address - Phone:304-728-1642
Mailing Address - Fax:
Practice Address - Street 1:300 S PRESTON ST
Practice Address - Street 2:
Practice Address - City:RANSON
Practice Address - State:WV
Practice Address - Zip Code:25438-1631
Practice Address - Country:US
Practice Address - Phone:304-728-1642
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-27
Last Update Date:2015-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV67049163W00000X
MDR177378163W00000X
VA0001215789163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse