Provider Demographics
NPI:1255632675
Name:BLAYLOCK, NICKLOS
Entity type:Individual
Prefix:MR
First Name:NICKLOS
Middle Name:
Last Name:BLAYLOCK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 20TH AVE
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-3109
Mailing Address - Country:US
Mailing Address - Phone:631-328-4292
Mailing Address - Fax:631-647-4613
Practice Address - Street 1:19 20TH AVE
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-3109
Practice Address - Country:US
Practice Address - Phone:631-328-4292
Practice Address - Fax:631-647-4613
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-17
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY590968-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse