Healthcare Provider Details

I. General information

NPI: 1477234888
Provider Name (Legal Business Name): CASEY BLALOCK MSN, APRN, CNS, CPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2023
Last Update Date: 07/27/2023
Certification Date: 07/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3020 CHILDRENS WAY
SAN DIEGO CA
92123-4223
US

IV. Provider business mailing address

11292 CAPILLA RD
SAN DIEGO CA
92127-1445
US

V. Phone/Fax

Practice location:
  • Phone: 858-576-1700
  • Fax:
Mailing address:
  • Phone: 858-472-0684
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number600988
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code364SP0200X
TaxonomyPediatric Clinical Nurse Specialist
License Number4226
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: