MEDICARE: DESTYNI BLAYLOCK ARNP

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	363L00000X	Nurse Practitioner	9380591	FL

General Provider Information

NPI Number	:	1386121135
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DESTYNI BLAYLOCK ARNP

Provider Business Mailing Address
First Line	:	137 MARINDA PL
Second Line	:
City	:	SAINT JOHNS
State	:	FL
Zip	:	32259-1264
Country	:	US
Telephone Number	:	904-803-1656
Fax Number	:

Provider Business Practice Location Address
First Line	:	1375 CASSAT AVE
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32205-7084
Country	:	US
Telephone Number	:	904-388-2820
Fax Number	:

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

Provider Enumeration Date	:	07/24/2018
Last Update Date	:	07/24/2018

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