Provider Demographics
NPI:1649773649
Name:BLALOCK, KRISTY K (RN)
Entity Type:Individual
Prefix:MRS
First Name:KRISTY
Middle Name:K
Last Name:BLALOCK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 CR SW 3020
Mailing Address - Street 2:
Mailing Address - City:MT VERNON
Mailing Address - State:TX
Mailing Address - Zip Code:75457
Mailing Address - Country:US
Mailing Address - Phone:903-439-7978
Mailing Address - Fax:
Practice Address - Street 1:3605 NE LOOP 286 STE 200
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:TX
Practice Address - Zip Code:75460-5091
Practice Address - Country:US
Practice Address - Phone:903-737-4337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-15
Last Update Date:2018-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX858507163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX858507OtherREGISTERED NURSE