Provider Demographics
NPI:1487452116
Name:BLALACK, ASHLEY MARIE (RN)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:MARIE
Last Name:BLALACK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2090 S LYNN RIGGS BLVD APT 37
Mailing Address - Street 2:
Mailing Address - City:CLAREMORE
Mailing Address - State:OK
Mailing Address - Zip Code:74019-5545
Mailing Address - Country:US
Mailing Address - Phone:479-280-8130
Mailing Address - Fax:
Practice Address - Street 1:6333 E SKELLY DR
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-6101
Practice Address - Country:US
Practice Address - Phone:918-779-7117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-07
Last Update Date:2025-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR105889163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)