Provider Demographics
NPI:1679931414
Name:BLALOCK, ASHLEY
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
Last Name:BLALOCK
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 1:2373 AUGUSTA ST
Mailing Address - Street 2:
Mailing Address - City:DYERSBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38024-8942
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4903 BRUCEVILLE SLAB RD
Practice Address - Street 2:
Practice Address - City:FRIENDSHIP
Practice Address - State:TN
Practice Address - Zip Code:38034-4325
Practice Address - Country:US
Practice Address - Phone:731-676-0393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-08
Last Update Date:2022-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN21250363LF0000X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1679931414Medicaid