Healthcare Provider Details

I. General information

NPI: 1932169612
Provider Name (Legal Business Name): MARY COFFEY BLALOCK OB-GYN NURSE PRACT.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARY ALICE BLALOCK OB-GYN NURSE PRACT.

II. Dates (important events)

Enumeration Date: 03/25/2006
Last Update Date: 04/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

177 NEW VALE RD OFFICE OF E.H. PEREZ, MD
NEWLAND NC
28657-9198
US

IV. Provider business mailing address

PO BOX 245 190 AARON CHURCH LN.
MONTEZUMA NC
28653-0245
US

V. Phone/Fax

Practice location:
  • Phone: 828-733-0085
  • Fax:
Mailing address:
  • Phone: 828-733-3358
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number0800049
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: