Provider Demographics
NPI:1194289298
Name:BLAKLEY, JOHN PAUL (FNP-C)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:PAUL
Last Name:BLAKLEY
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 HOLSTON AVE STE B
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:TN
Mailing Address - Zip Code:37620-3592
Mailing Address - Country:US
Mailing Address - Phone:423-968-1772
Mailing Address - Fax:423-968-5736
Practice Address - Street 1:607 HOLSTON AVE STE B
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-3592
Practice Address - Country:US
Practice Address - Phone:423-968-1772
Practice Address - Fax:239-685-7364
Is Sole Proprietor?:No
Enumeration Date:2019-01-23
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11001099363L00000X
TN26463363LP2300X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care