Provider Demographics
NPI:1588341200
Name:BLAYLOCK, BART L (RN)
Entity type:Individual
Prefix:
First Name:BART
Middle Name:L
Last Name:BLAYLOCK
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15810 N 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85053-4074
Mailing Address - Country:US
Mailing Address - Phone:807-588-6264
Mailing Address - Fax:
Practice Address - Street 1:15810 N 28TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85053-4074
Practice Address - Country:US
Practice Address - Phone:480-758-8626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-04
Last Update Date:2023-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN144618163WC0400X, 163WA2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA2000XNursing Service ProvidersRegistered NurseAdministrator
No163WC0400XNursing Service ProvidersRegistered NurseCase Management