Provider Demographics
NPI:1376389858
Name:BLAYLOCK, CABRINA
Entity type:Individual
Prefix:MISS
First Name:CABRINA
Middle Name:
Last Name:BLAYLOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 W COMMONWEALTH AVE STE 213
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92832-1752
Mailing Address - Country:US
Mailing Address - Phone:562-375-5874
Mailing Address - Fax:
Practice Address - Street 1:22675 HILLS RANCH RD
Practice Address - Street 2:
Practice Address - City:NUEVO
Practice Address - State:CA
Practice Address - Zip Code:92567-9096
Practice Address - Country:US
Practice Address - Phone:562-375-5874
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-03
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA330214AP2083A0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083A0300XAllopathic & Osteopathic PhysiciansPreventive MedicineAddiction Medicine