Provider Demographics
NPI:1386121135
Name:BLAYLOCK, DESTYNI (ARNP)
Entity type:Individual
Prefix:
First Name:DESTYNI
Middle Name:
Last Name:BLAYLOCK
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 MARINDA PL
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259-1264
Mailing Address - Country:US
Mailing Address - Phone:904-803-1656
Mailing Address - Fax:
Practice Address - Street 1:1375 CASSAT AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32205-7084
Practice Address - Country:US
Practice Address - Phone:904-388-2820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-24
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9380591363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner