Provider Demographics
NPI:1437820974
Name:BALLARD, BLAKE DARBY
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:DARBY
Last Name:BALLARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:675 BURBANK DR SE
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-1823
Mailing Address - Country:US
Mailing Address - Phone:662-425-9377
Mailing Address - Fax:
Practice Address - Street 1:1462 CLIFTON RD NE STE 280
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30322-1063
Practice Address - Country:US
Practice Address - Phone:404-727-7825
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-23
Last Update Date:2025-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11576363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty