Basic Information
| Provider Information | |||||||||
| NPI: | 1659947828 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLAYLOCK | ||||||||
| FirstName: | TYRANI | ||||||||
| MiddleName: | NASHELLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4400 N LINCOLN BLVD | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731055108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4054247711 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7777 E US HIGHWAY 66 | ||||||||
| Address2: | |||||||||
| City: | EL RENO | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730369125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4054228800 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2021 | ||||||||
| LastUpdateDate: | 05/28/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | OK | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.