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General NPI Number Information
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NPI Number | 1346638905
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Entity Type | Individual
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Provider Name | GABRIELLE N. BLAYLOCK PA-C, ATC
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Gender | Female
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Dates
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Enumeration Date | 01/06/2015
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Last Update Date | 05/16/2025
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Provider Practice Location Address
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Address Line | 156 FOSTER DR STE B
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City | MCDONOUGH
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State | GA
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Zip | 30253-5346
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Country | US
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Telephone | 770-506-4119
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Fax |
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Provider Business Mailing Address
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Address Line | 675 LAFAYETTE AVE APT 3207
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City | FAYETTEVILLE
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State | GA
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Zip | 30214-5553
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 12282
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License Number State | GA
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