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General NPI Number Information
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NPI Number | 1740681279
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Entity Type | Individual
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Provider Name | AMANDA R BLALOCK NP
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Gender | Female
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Dates
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Enumeration Date | 09/16/2014
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Last Update Date | 03/20/2025
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Provider Practice Location Address
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Address Line | 1800 SHILOH RD STE 104
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City | TYLER
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State | TX
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Zip | 75703-2456
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Country | US
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Telephone | 903-969-5125
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Fax | 207-536-2445
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Provider Business Mailing Address
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Address Line | 1800 SHILOH RD STE 104
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City | TYLER
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State | TX
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Zip | 75703-2456
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Country | US
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Telephone | 903-969-5125
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Fax | 207-536-2445
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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 | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | AP144205
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License Number State | TX
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