Healthcare Provider Details

I. General information

NPI: 1700105061
Provider Name (Legal Business Name): CYNTHIA BLAYLOCK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2010
Last Update Date: 05/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 GASTON AVE
DALLAS TX
75246-2017
US

IV. Provider business mailing address

1301 CONCORD TER
SUNRISE FL
33323-2843
US

V. Phone/Fax

Practice location:
  • Phone: 214-820-2806
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number637927
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: