Provider Demographics
NPI:1578570131
Name:BLAYLOCK, ANN G (APN)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:G
Last Name:BLAYLOCK
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:14 PARKSTONE CIR
Mailing Address - Street 2:
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72116-7086
Mailing Address - Country:US
Mailing Address - Phone:501-834-8507
Mailing Address - Fax:501-748-3334
Practice Address - Street 1:14 PARKSTONE CIR
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72116-7086
Practice Address - Country:US
Practice Address - Phone:501-748-3333
Practice Address - Fax:510-748-3334
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2015-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARSOO1002364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist