Provider Demographics
NPI:1346638905
Name:BLAYLOCK, GABRIELLE NICOLE (PA-C, ATC)
Entity type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:NICOLE
Last Name:BLAYLOCK
Suffix:
Gender:
Credentials:PA-C, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 INTERSTATE NORTH CIR SE STE 500
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-2296
Mailing Address - Country:US
Mailing Address - Phone:770-953-6929
Mailing Address - Fax:
Practice Address - Street 1:1265 HIGHWAY 54 W STE 200
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-4543
Practice Address - Country:US
Practice Address - Phone:770-460-1900
Practice Address - Fax:770-719-1214
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-06
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
GA12282363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer