Healthcare Provider Details

I. General information

NPI: 1043518756
Provider Name (Legal Business Name): TERA D MAPLE APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TERA D BLACKMON

II. Dates (important events)

Enumeration Date: 03/03/2011
Last Update Date: 09/15/2025
Certification Date: 09/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 E ROLLINS ST
ORLANDO FL
32803-1248
US

IV. Provider business mailing address

601 E ROLLINS ST
ORLANDO FL
32803-1248
US

V. Phone/Fax

Practice location:
  • Phone: 407-303-7283
  • Fax:
Mailing address:
  • Phone: 407-303-7283
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License NumberAPRN9264398
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAPRN9264398
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: