Provider Demographics
NPI:1710701560
Name:BLYSTONE, TIA ANGELIQUE (CRNP)
Entity type:Individual
Prefix:MRS
First Name:TIA
Middle Name:ANGELIQUE
Last Name:BLYSTONE
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 NEWHOUSE RD
Mailing Address - Street 2:
Mailing Address - City:NEW ALEXANDRIA
Mailing Address - State:PA
Mailing Address - Zip Code:15670-2584
Mailing Address - Country:US
Mailing Address - Phone:724-691-1169
Mailing Address - Fax:
Practice Address - Street 1:134 NEWHOUSE RD
Practice Address - Street 2:
Practice Address - City:NEW ALEXANDRIA
Practice Address - State:PA
Practice Address - Zip Code:15670-2584
Practice Address - Country:US
Practice Address - Phone:724-691-1169
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-08
Last Update Date:2024-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP031129363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty