Provider Demographics
NPI:1811630643
Name:BLAYLOCK, STEPHANIE JEMESE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:JEMESE
Last Name:BLAYLOCK
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 1:4190 BELFORT RD STE 352
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-1407
Mailing Address - Country:US
Mailing Address - Phone:904-372-3943
Mailing Address - Fax:904-212-1618
Practice Address - Street 1:50 MEDICAL PARK DR E
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35235-3401
Practice Address - Country:US
Practice Address - Phone:904-372-3943
Practice Address - Fax:904-212-1618
Is Sole Proprietor?:No
Enumeration Date:2022-04-19
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-123442363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily