MEDICARE: TYLETTA MARSHBANKS BLAKELY

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	172V00000X	Community Health Worker	20701	TX
2	171M00000X	Case Manager/Care Coordinator		TX

General Provider Information

NPI Number	:	1982495453
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TYLETTA MARSHBANKS BLAKELY

Provider Business Mailing Address
First Line	:	1708 LAKE POINT CT
Second Line	:
City	:	LITTLE ELM
State	:	TX
Zip	:	75068-8428
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2601 LITTLE ELM PKWY STE 1803
Second Line	:
City	:	LITTLE ELM
State	:	TX
Zip	:	75068-2503
Country	:	US
Telephone Number	:	214-724-4682
Fax Number	:

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

Provider Enumeration Date	:	05/14/2025
Last Update Date	:	01/08/2026

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