Provider Demographics
NPI:1841870268
Name:BLAYLOCK, SARAH MONIQUE
Entity type:Individual
Prefix:MS
First Name:SARAH
Middle Name:MONIQUE
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 1:432 ASH ST
Mailing Address - Street 2:
Mailing Address - City:RED BLUFF
Mailing Address - State:CA
Mailing Address - Zip Code:96080-3808
Mailing Address - Country:US
Mailing Address - Phone:530-392-2593
Mailing Address - Fax:
Practice Address - Street 1:109 PARMAC RD STE 1
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95926-2294
Practice Address - Country:US
Practice Address - Phone:530-891-2945
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-09
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41712167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes167G00000XNursing Service ProvidersLicensed Psychiatric TechnicianGroup - Single Specialty