Healthcare Provider Details

I. General information

NPI: 1922076124
Provider Name (Legal Business Name): DAVID JUSTIN BLALOCK ARNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 08/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 CARLTON ST
WAUCHULA FL
33873-3407
US

IV. Provider business mailing address

515 CARLTON ST
WAUCHULA FL
33873-3407
US

V. Phone/Fax

Practice location:
  • Phone: 863-773-6606
  • Fax:
Mailing address:
  • Phone: 863-773-6606
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberARNP2833192
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: