Basic Information
| Provider Information | |||||||||
| NPI: | 1609178094 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLAYLOCK | ||||||||
| FirstName: | KRISTA | ||||||||
| MiddleName: | BAIN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 864 WILSON DR | ||||||||
| Address2: | SUITE C | ||||||||
| City: | RIDGELAND | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391574512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012066100 | ||||||||
| FaxNumber: | 6012066052 | ||||||||
| Practice Location | |||||||||
| Address1: | 332 HIGHWAY 12 W | ||||||||
| Address2: | |||||||||
| City: | KOSCIUSKO | ||||||||
| State: | MS | ||||||||
| PostalCode: | 390903209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6622891800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2010 | ||||||||
| LastUpdateDate: | 08/21/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | R863824 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 364SF0001X | R863824 | MS | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Family Health |
No ID Information.