Provider Demographics
NPI:1669614160
Name:BLAYLOCK, ALISHA MICHELE (BSN)
Entity type:Individual
Prefix:
First Name:ALISHA
Middle Name:MICHELE
Last Name:BLAYLOCK
Suffix:
Gender:F
Credentials:BSN
Other - Prefix:
Other - First Name:A.
Other - Middle Name:MICHELE
Other - Last Name:BLAYLOCK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BSN
Mailing Address - Street 1:1167 SPRATLIN PARK DR
Mailing Address - Street 2:
Mailing Address - City:GRAY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-6205
Mailing Address - Country:US
Mailing Address - Phone:423-467-3600
Mailing Address - Fax:423-467-3644
Practice Address - Street 1:200 W FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-5611
Practice Address - Country:US
Practice Address - Phone:423-467-3600
Practice Address - Fax:423-467-3644
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-30
Last Update Date:2009-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN0000121665163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse