Provider Demographics
NPI:1144009143
Name:BLAYLOCK, VICTORIA BROOKE (FNP-C)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:BROOKE
Last Name:BLAYLOCK
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 1:108 NE 6TH ST
Mailing Address - Street 2:
Mailing Address - City:WILBURTON
Mailing Address - State:OK
Mailing Address - Zip Code:74578-3012
Mailing Address - Country:US
Mailing Address - Phone:918-638-4182
Mailing Address - Fax:
Practice Address - Street 1:340 S GEORGE NIGH EXPY
Practice Address - Street 2:
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501-6075
Practice Address - Country:US
Practice Address - Phone:918-420-9854
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-27
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK215360363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily