Provider Demographics
NPI:1437790946
Name:BLAYLOCK, ELIZABETH ANN (RPSGT, RST, CCSH)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANN
Last Name:BLAYLOCK
Suffix:
Gender:F
Credentials:RPSGT, RST, CCSH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3476 HUNTERFIELD TRL
Mailing Address - Street 2:
Mailing Address - City:BARTLETT
Mailing Address - State:TN
Mailing Address - Zip Code:38135-3012
Mailing Address - Country:US
Mailing Address - Phone:901-461-4761
Mailing Address - Fax:901-377-4885
Practice Address - Street 1:130 TIMBER CREEK DR
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38018-4200
Practice Address - Country:US
Practice Address - Phone:901-842-1392
Practice Address - Fax:901-842-1393
Is Sole Proprietor?:No
Enumeration Date:2019-10-05
Last Update Date:2021-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN9246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other