Provider Demographics
NPI:1588043400
Name:BLAYLOCK, CASSANDRA (NP)
Entity type:Individual
Prefix:MRS
First Name:CASSANDRA
Middle Name:
Last Name:BLAYLOCK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:CASSANDRA
Other - Middle Name:
Other - Last Name:YAMAGUCHI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5767 W CENTURY BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1250 16TH ST
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-1249
Practice Address - Country:US
Practice Address - Phone:424-259-9457
Practice Address - Fax:424-259-6823
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-26
Last Update Date:2025-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95003118207RH0003X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily