Provider Demographics
NPI:1346955168
Name:REVLETT, BLAKE
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:REVLETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2220 SPAIN HILL RD
Mailing Address - Street 2:
Mailing Address - City:LASCASSAS
Mailing Address - State:TN
Mailing Address - Zip Code:37085-5143
Mailing Address - Country:US
Mailing Address - Phone:615-785-9563
Mailing Address - Fax:
Practice Address - Street 1:1508 CARL ADAMS DR UNIT 200
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37129-4375
Practice Address - Country:US
Practice Address - Phone:615-893-4896
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-16
Last Update Date:2023-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA0000005269363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant