Provider Demographics
NPI:1962043406
Name:BLAYLOCK, MARI CAITLYNE (FNP-C)
Entity Type:Individual
Prefix:MS
First Name:MARI
Middle Name:CAITLYNE
Last Name:BLAYLOCK
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:MS
Other - First Name:MARI
Other - Middle Name:CAITLYNE
Other - Last Name:HARRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-C
Mailing Address - Street 1:1506 HIGHWAY 278 E STE A
Mailing Address - Street 2:
Mailing Address - City:AMORY
Mailing Address - State:MS
Mailing Address - Zip Code:38821-5906
Mailing Address - Country:US
Mailing Address - Phone:662-597-2019
Mailing Address - Fax:662-597-2034
Practice Address - Street 1:499 GLOSTER CREEK VLG STE D1
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-4753
Practice Address - Country:US
Practice Address - Phone:662-690-8007
Practice Address - Fax:662-842-4653
Is Sole Proprietor?:No
Enumeration Date:2019-10-07
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS903562363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07582036Medicaid