Healthcare Provider Details

I. General information

NPI: 1811630643
Provider Name (Legal Business Name): STEPHANIE JEMESE BLAYLOCK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2022
Last Update Date: 04/19/2022
Certification Date: 04/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 MEDICAL PARK DR E
BIRMINGHAM AL
35235-3401
US

IV. Provider business mailing address

4190 BELFORT RD STE 352
JACKSONVILLE FL
32216-1407
US

V. Phone/Fax

Practice location:
  • Phone: 904-372-3943
  • Fax: 904-212-1618
Mailing address:
  • Phone: 904-372-3943
  • Fax: 904-212-1618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1-123442
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: