Provider Demographics
NPI:1376309708
Name:BLAKELY, MARIAN ANNETTE (FNP)
Entity type:Individual
Prefix:
First Name:MARIAN
Middle Name:ANNETTE
Last Name:BLAKELY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:MARIAN
Other - Middle Name:
Other - Last Name:SIMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:ONE GI CREDENTIALING DEPARTMENT
Mailing Address - Street 2:PO BOX 381468
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38183-1468
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8000 WOLF RIVER BLVD STE 200
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-1755
Practice Address - Country:US
Practice Address - Phone:901-747-3630
Practice Address - Fax:901-747-4149
Is Sole Proprietor?:No
Enumeration Date:2024-02-23
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN35770363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily