MEDICARE: ANN G BLAYLOCK APN

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	364S00000X	Clinical Nurse Specialist	SOO1002	AR

General Provider Information

NPI Number	:	1578570131
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANN G BLAYLOCK APN

Provider Business Mailing Address
First Line	:	14 PARKSTONE CIR
Second Line	:
City	:	NORTH LITTLE ROCK
State	:	AR
Zip	:	72116-7086
Country	:	US
Telephone Number	:	501-834-8507
Fax Number	:	501-748-3334

Provider Business Practice Location Address
First Line	:	14 PARKSTONE CIR
Second Line	:
City	:	NORTH LITTLE ROCK
State	:	AR
Zip	:	72116-7086
Country	:	US
Telephone Number	:	501-748-3333
Fax Number	:	510-748-3334

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

Provider Enumeration Date	:	08/03/2006
Last Update Date	:	08/13/2015

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