Provider Demographics
NPI:1043199896
Name:BLAIN, ALEXANDRIA SELENA
Entity type:Individual
Prefix:
First Name:ALEXANDRIA
Middle Name:SELENA
Last Name:BLAIN
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 1:6505 ESCENA ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92407-5121
Mailing Address - Country:US
Mailing Address - Phone:909-991-4377
Mailing Address - Fax:
Practice Address - Street 1:214 N PALM AVE STE 504
Practice Address - Street 2:
Practice Address - City:RIALTO
Practice Address - State:CA
Practice Address - Zip Code:92376-5826
Practice Address - Country:US
Practice Address - Phone:909-685-3897
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-27
Last Update Date:2025-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker