Healthcare Provider Details

I. General information

NPI: 1154738821
Provider Name (Legal Business Name): CLYDE BLAYLOCK FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2014
Last Update Date: 04/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8725 N WICKHAM RD STE 301
MELBOURNE FL
32940-2240
US

IV. Provider business mailing address

3300 S FISKE BLVD
ROCKLEDGE FL
32955-4306
US

V. Phone/Fax

Practice location:
  • Phone: 321-434-9200
  • Fax: 321-434-9202
Mailing address:
  • Phone: 321-434-9200
  • Fax: 321-951-7408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberARNP9210359
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: