Provider Demographics
NPI:1700871316
Name:BLAYLOCK, REBECCA C (CRNA)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:C
Last Name:BLAYLOCK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:POST OFFICE BOX 22926
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225-2926
Mailing Address - Country:US
Mailing Address - Phone:713-400-2990
Mailing Address - Fax:713-400-2993
Practice Address - Street 1:1635 NORTH LOOP WEST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77008-1593
Practice Address - Country:US
Practice Address - Phone:713-400-2990
Practice Address - Fax:713-400-2993
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX250188367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX088840604Medicaid
TX430070601OtherRAILROAD MEDICARE
TX088840608Medicaid
TX1606097-02Medicaid
TX86922UOtherBCBS - TAC HOU
TX87204UOtherBLUE CROSS PROV ID-GHA
TX82315UOtherBLUE CROSS BLUE SHIELD
TX84290UOtherBLUE CROSS BLUE SHIELD
8J3889Medicare PIN
TX86762HMedicare PIN