Provider Demographics
NPI:1194685206
Name:EVERSOLE, BLAISE CHERIE
Entity type:Individual
Prefix:
First Name:BLAISE
Middle Name:CHERIE
Last Name:EVERSOLE
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 1:2106 E BERMUDA ST APT 206
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90814-6066
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2120 W WILLIAMS ST
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90810-3636
Practice Address - Country:US
Practice Address - Phone:562-388-8118
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-11-12
Last Update Date:2025-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program