Healthcare Provider Details

I. General information

NPI: 1508711904
Provider Name (Legal Business Name): CHARLA GERI BLACKWELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2026
Last Update Date: 03/02/2026
Certification Date: 03/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

613 MARQUETTE RD
BRANDON MS
39042-3038
US

IV. Provider business mailing address

128 WILLOW CREST CIR
BRANDON MS
39047-7064
US

V. Phone/Fax

Practice location:
  • Phone: 601-824-1692
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number883208
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: