Provider Demographics
NPI:1659947828
Name:BLAYLOCK - THOMAS, TYRANI NASHELLE
Entity Type:Individual
Prefix:MRS
First Name:TYRANI
Middle Name:NASHELLE
Last Name:BLAYLOCK - THOMAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4400 N LINCOLN BLVD
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73105-5108
Mailing Address - Country:US
Mailing Address - Phone:405-424-7711
Mailing Address - Fax:
Practice Address - Street 1:7777 E US HIGHWAY 66
Practice Address - Street 2:
Practice Address - City:EL RENO
Practice Address - State:OK
Practice Address - Zip Code:73036-9125
Practice Address - Country:US
Practice Address - Phone:405-422-8800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-28
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator