Healthcare Provider Details

I. General information

NPI: 1356623961
Provider Name (Legal Business Name): DENISE NANETTE BLACKBOURNE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2011
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 ORLEANS ST
BALTIMORE MD
21287-0010
US

IV. Provider business mailing address

6201 GREENLEIGH AVE
MIDDLE RIVER MD
21220-2004
US

V. Phone/Fax

Practice location:
  • Phone: 410-502-2037
  • Fax:
Mailing address:
  • Phone: 410-955-5000
  • Fax: 410-500-4266

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberC0007330
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: