Provider Demographics
NPI:1952625030
Name:BLALOCK, SHEILA R (APN)
Entity Type:Individual
Prefix:MRS
First Name:SHEILA
Middle Name:R
Last Name:BLALOCK
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:229 INTERSTATE DR
Mailing Address - Street 2:SUITE 105
Mailing Address - City:CROSSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38555-2709
Mailing Address - Country:US
Mailing Address - Phone:931-484-2220
Mailing Address - Fax:931-484-2225
Practice Address - Street 1:4147 HIGHWAY 127 N STE 102
Practice Address - Street 2:
Practice Address - City:CROSSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38571-7521
Practice Address - Country:US
Practice Address - Phone:931-484-2220
Practice Address - Fax:931-484-2225
Is Sole Proprietor?:No
Enumeration Date:2010-03-18
Last Update Date:2019-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN14809363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3849058Medicaid