MEDICARE: BLAY LONGEVITY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1124842299
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLAY LONGEVITY

Provider Business Mailing Address
First Line	:	1010 N 12TH AVE STE 307
Second Line	:
City	:	PENSACOLA
State	:	FL
Zip	:	32501-3492
Country	:	US
Telephone Number	:	407-617-4361
Fax Number	:

Provider Business Practice Location Address
First Line	:	1010 N 12TH AVE STE 307
Second Line	:
City	:	PENSACOLA
State	:	FL
Zip	:	32501-3492
Country	:	US
Telephone Number	:	407-617-4361
Fax Number	:

Authorized Official
Title or Position	:	NURSE PRACTITIONER
Name	:	NICOLE BLAY
Credential	:	APRN
Telephone Number	:	407-617-4361

Provider Enumeration Date	:	11/14/2024
Last Update Date	:	11/14/2024

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Directions to “BLAY LONGEVITY ” Practice Location

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