Individual
BLAISE FONDREN
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
2222 JACKSON AVE W, OXFORD, MS 38655-5409
(662) 380-5560
Mailing address
420 LIVE OAK DR, OXFORD, MS 38655-2962
(901) 337-5548
Taxonomy
Speciality
Code
Description
License number
State
163W00000X
Registered Nurse
899036
MS
363LF0000X
Family Nurse Practitioner
36596
TN
363LF0000X
Family Nurse Practitioner
Primary
906484
MS
Other
Enumeration date
12/19/2023
Last updated
07/28/2025
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