Healthcare Provider Details

I. General information

NPI: 1467368274
Provider Name (Legal Business Name): BELLA R BLAYLOCK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2026
Last Update Date: 08/21/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1207 CARLSBAD VILLAGE DR STE N
CARLSBAD CA
92008-1958
US

IV. Provider business mailing address

3185 SANDY PL
CARLSBAD CA
92008-1139
US

V. Phone/Fax

Practice location:
  • Phone: 760-717-2630
  • Fax:
Mailing address:
  • Phone: 760-717-2630
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: