Healthcare Provider Details

I. General information

NPI: 1063379857
Provider Name (Legal Business Name): CHRISTINA BLANCHARD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2026
Last Update Date: 01/05/2026
Certification Date: 01/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6619 N WICKHAM RD
MELBOURNE FL
32940-2006
US

IV. Provider business mailing address

111 SNEAD RD APT C
INDIAN HARBOUR BEACH FL
32937-5380
US

V. Phone/Fax

Practice location:
  • Phone: 321-259-9500
  • Fax:
Mailing address:
  • Phone: 321-517-1080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberNO
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: