Basic Information
| Provider Information | |||||||||
| NPI: | 1962043406 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLAYLOCK | ||||||||
| FirstName: | MARI | ||||||||
| MiddleName: | CAITLYNE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | FNP-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HARRIS | ||||||||
| OtherFirstName: | MARI | ||||||||
| OtherMiddleName: | CAITLYNE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | FNP-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1506 HIGHWAY 278 E STE A | ||||||||
| Address2: | |||||||||
| City: | AMORY | ||||||||
| State: | MS | ||||||||
| PostalCode: | 388215906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6625972019 | ||||||||
| FaxNumber: | 6625972034 | ||||||||
| Practice Location | |||||||||
| Address1: | 499 GLOSTER CREEK VLG STE D1 | ||||||||
| Address2: | |||||||||
| City: | TUPELO | ||||||||
| State: | MS | ||||||||
| PostalCode: | 388014753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6626908007 | ||||||||
| FaxNumber: | 6628424653 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2019 | ||||||||
| LastUpdateDate: | 07/28/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 903562 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 07582036 | 05 | MS | MEDICAID |