MEDICARE: GABRIELLE N. BLAYLOCK PA-C, ATC

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	2255A2300X	Athletic Trainer
2	363A00000X	Physician Assistant
3	363A00000X	Physician Assistant	12282	GA

General Provider Information

NPI Number	:	1346638905
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GABRIELLE N. BLAYLOCK PA-C, ATC

Provider Business Mailing Address
First Line	:	675 LAFAYETTE AVE APT 3207
Second Line	:
City	:	FAYETTEVILLE
State	:	GA
Zip	:	30214-5553
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	156 FOSTER DR STE B
Second Line	:
City	:	MCDONOUGH
State	:	GA
Zip	:	30253-5346
Country	:	US
Telephone Number	:	770-506-4119
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/06/2015
Last Update Date	:	05/16/2025

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