Provider Demographics
NPI:1376309708
Name:BLAKELY, MARIAN ANNETTE (FNP)
Entity Type:Individual
Prefix:
First Name:MARIAN
Middle Name:ANNETTE
Last Name:BLAKELY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:MARIAN
Other - Middle Name:
Other - Last Name:SIMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:65 GERMANTOWN CT STE 300
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38018-4258
Mailing Address - Country:US
Mailing Address - Phone:901-737-4665
Mailing Address - Fax:901-328-1355
Practice Address - Street 1:8000 WOLF RIVER BLVD STE 200
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-1755
Practice Address - Country:US
Practice Address - Phone:901-747-3630
Practice Address - Fax:901-747-4149
Is Sole Proprietor?:No
Enumeration Date:2024-02-23
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN220067363LF0000X
TN35770363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily