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: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4470 REGENCY PL
WHITE PLAINS MD
20695-3085
US

IV. Provider business mailing address

4470 REGENCY PL
WHITE PLAINS MD
20695-3085
US

V. Phone/Fax

Practice location:
  • Phone: 240-252-2140
  • Fax:
Mailing address:
  • Phone:
  • Fax:

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: