Provider Demographics
NPI:1497212302
Name:BLAKLEY, TRACEY NYCOLE (FNP)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:NYCOLE
Last Name:BLAKLEY
Suffix:
Gender:F
Credentials:FNP
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 40
Mailing Address - Street 2:
Mailing Address - City:WHITESBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41858-0040
Mailing Address - Country:US
Mailing Address - Phone:606-633-4823
Mailing Address - Fax:
Practice Address - Street 1:1620 E MAIN ST
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:KY
Practice Address - Zip Code:40823
Practice Address - Country:US
Practice Address - Phone:606-589-6113
Practice Address - Fax:606-589-4436
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-27
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3012958363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily