Provider Demographics
NPI:1154738821
Name:BLAYLOCK, CLYDE (FNP-BC)
Entity type:Individual
Prefix:
First Name:CLYDE
Middle Name:
Last Name:BLAYLOCK
Suffix:
Gender:M
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-434-9200
Mailing Address - Fax:321-951-7408
Practice Address - Street 1:8725 N WICKHAM RD STE 301
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-2240
Practice Address - Country:US
Practice Address - Phone:321-434-9200
Practice Address - Fax:321-434-9202
Is Sole Proprietor?:No
Enumeration Date:2014-07-15
Last Update Date:2019-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9210359363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLHX161ZOtherMEDICARE
FL014541700Medicaid
FLHX161YOtherMEDICARE