Healthcare Provider Details

I. General information

NPI: 1770382533
Provider Name (Legal Business Name): NIKITA BLAKENEY-WILLIAMS FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2025
Last Update Date: 08/21/2025
Certification Date: 08/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4401 E INDEPENDENCE BLVD STE 208F
CHARLOTTE NC
28205-7485
US

IV. Provider business mailing address

PO BOX 37054
ROCK HILL SC
29732-0517
US

V. Phone/Fax

Practice location:
  • Phone: 980-402-4668
  • Fax: 888-830-9448
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number30104
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number30104
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code364SC1501X
TaxonomyCommunity Health/Public Health Clinical Nurse Specialist
License Number207581
License Number StateSC
# 4
Primary TaxonomyN
Taxonomy Code364SL0600X
TaxonomyLong-Term Care Clinical Nurse Specialist
License Number207581
License Number StateSC
# 5
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number5021996
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: