Provider Demographics
NPI:1609178094
Name:BLAYLOCK, KRISTA BAIN (NP)
Entity type:Individual
Prefix:MRS
First Name:KRISTA
Middle Name:BAIN
Last Name:BLAYLOCK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:864 WILSON DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-4512
Mailing Address - Country:US
Mailing Address - Phone:601-206-6100
Mailing Address - Fax:601-206-6052
Practice Address - Street 1:332 HIGHWAY 12 W
Practice Address - Street 2:
Practice Address - City:KOSCIUSKO
Practice Address - State:MS
Practice Address - Zip Code:39090-3209
Practice Address - Country:US
Practice Address - Phone:662-289-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-17
Last Update Date:2015-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR863824363L00000X, 364SF0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health