Provider Demographics
NPI:1346638905
Name:BLAYLOCK, GABRIELLE N (PA-C, ATC)
Entity type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:N
Last Name:BLAYLOCK
Suffix:
Gender:F
Credentials:PA-C, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:675 LAFAYETTE AVE APT 3207
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-5553
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:156 FOSTER DR STE B
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-5346
Practice Address - Country:US
Practice Address - Phone:770-506-4119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-06
Last Update Date:2025-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X, 363A00000X
GA12282363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer