Provider Demographics
NPI:1982923942
Name:BLAKLEY, MONICA V (FNP-C)
Entity type:Individual
Prefix:
First Name:MONICA
Middle Name:V
Last Name:BLAKLEY
Suffix:
Gender:F
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:PO BOX 511
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39403-0511
Mailing Address - Country:US
Mailing Address - Phone:601-450-0310
Mailing Address - Fax:601-450-0321
Practice Address - Street 1:605 STADIUM DR
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-4156
Practice Address - Country:US
Practice Address - Phone:601-450-0310
Practice Address - Fax:601-450-0321
Is Sole Proprietor?:No
Enumeration Date:2010-05-28
Last Update Date:2011-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR872218363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS12131306OtherCAQH ID
MS04157249Medicaid
MS9971504OtherAETNA PIN
MS04157249Medicaid