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General NPI Number Information
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NPI Number | 1255787511
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Entity Type | Individual
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Provider Name | BRENDA BLACKISTON NP-C
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Gender | Female
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Dates
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Enumeration Date | 05/05/2016
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Last Update Date | 06/20/2024
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Provider Practice Location Address
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Address Line | 401 WINSTON AVE
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City | WILMINGTON
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State | DE
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Zip | 19804-1818
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Country | US
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Telephone | 302-290-5390
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Fax | 302-993-1029
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Provider Business Mailing Address
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Address Line | 101 CHESAPEAKE BLVD STE B
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City | ELKTON
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State | MD
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Zip | 21921-6607
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Country | US
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Telephone | 903-948-8566
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Fax | 302-633-5844
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | LG-0000930
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License Number State | DE
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | LG-0000930
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License Number State | DE
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