Healthcare Provider Details

I. General information

NPI: 1962043406
Provider Name (Legal Business Name): MARI CAITLYNE BLAYLOCK FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARI CAITLYNE HARRIS FNP-C

II. Dates (important events)

Enumeration Date: 10/07/2019
Last Update Date: 05/07/2025
Certification Date: 05/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

499 GLOSTER CREEK VLG STE D1
TUPELO MS
38801-4753
US

IV. Provider business mailing address

1506 HIGHWAY 278 E STE A
AMORY MS
38821-5906
US

V. Phone/Fax

Practice location:
  • Phone: 662-690-8007
  • Fax: 662-842-4653
Mailing address:
  • Phone: 662-597-2019
  • Fax: 662-597-2034

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number903562
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: