Provider Demographics
NPI:1932169612
Name:BLALOCK, MARY COFFEY (OB-GYN NURSE PRACT)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:COFFEY
Last Name:BLALOCK
Suffix:
Gender:F
Credentials:OB-GYN NURSE PRACT
Other - Prefix:MRS
Other - First Name:MARY
Other - Middle Name:ALICE
Other - Last Name:BLALOCK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OB-GYN NURSE PRACT
Mailing Address - Street 1:PO BOX 245
Mailing Address - Street 2:190 AARON CHURCH LN.
Mailing Address - City:MONTEZUMA
Mailing Address - State:NC
Mailing Address - Zip Code:28653-0245
Mailing Address - Country:US
Mailing Address - Phone:828-733-3358
Mailing Address - Fax:
Practice Address - Street 1:177 NEW VALE RD
Practice Address - Street 2:OFFICE OF E.H. PEREZ, MD
Practice Address - City:NEWLAND
Practice Address - State:NC
Practice Address - Zip Code:28657-9198
Practice Address - Country:US
Practice Address - Phone:828-733-0085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-25
Last Update Date:2015-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0800049363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCF60595Medicare UPIN
NCE49888Medicare UPIN