Healthcare Provider Details

I. General information

NPI: 1750791612
Provider Name (Legal Business Name): MARILYN DONETTE BLACKMAN REGISTERED NURSE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2014
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CROSS ISLAND PLZ STE 210
ROSEDALE NY
11422-1456
US

IV. Provider business mailing address

537 POWELL ST PH
BROOKLYN NY
11212-7110
US

V. Phone/Fax

Practice location:
  • Phone: 718-978-4999
  • Fax:
Mailing address:
  • Phone: 718-304-4673
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number22 683025
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number22. 683025
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: