Provider Demographics
NPI:1346634011
Name:BLYLY, LAUREN (PA-C)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:BLYLY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20480 VERNIER RD
Mailing Address - Street 2:
Mailing Address - City:HARPER WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48225-1411
Mailing Address - Country:US
Mailing Address - Phone:248-938-0141
Mailing Address - Fax:
Practice Address - Street 1:20480 VERNIER RD
Practice Address - Street 2:
Practice Address - City:HARPER WOODS
Practice Address - State:MI
Practice Address - Zip Code:48225-1411
Practice Address - Country:US
Practice Address - Phone:248-938-0141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-20
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601012423363AM0700X
2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical