Healthcare Provider Details

I. General information

NPI: 1760767735
Provider Name (Legal Business Name): WEHTI BLACKLEDGE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2011
Last Update Date: 02/11/2021
Certification Date: 02/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15459 ANNAPOLIS RD
BOWIE MD
20715-1847
US

IV. Provider business mailing address

5000 COX RD
GLEN ALLEN VA
23060-9263
US

V. Phone/Fax

Practice location:
  • Phone: 240-544-0676
  • Fax:
Mailing address:
  • Phone: 804-968-5700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR166525
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1025280
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: