Healthcare Provider Details

I. General information

NPI: 1376309708
Provider Name (Legal Business Name): MARIAN ANNETTE BLAKELY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARIAN SIMS

II. Dates (important events)

Enumeration Date: 02/23/2024
Last Update Date: 03/03/2025
Certification Date: 03/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8000 WOLF RIVER BLVD STE 200
GERMANTOWN TN
38138-1755
US

IV. Provider business mailing address

ONE GI CREDENTIALING DEPARTMENT PO BOX 381468
GERMANTOWN TN
38183-1468
US

V. Phone/Fax

Practice location:
  • Phone: 901-747-3630
  • Fax: 901-747-4149
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number35770
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: