=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770382533
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NIKITA BLAKENEY-WILLIAMS FNP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/12/2025
-----------------------------------------------------
Last Update Date | 08/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4401 E INDEPENDENCE BLVD STE 208F
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28205-7485
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 980-402-4668
-----------------------------------------------------
Fax | 888-830-9448
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 37054
-----------------------------------------------------
City | ROCK HILL
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29732-0517
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 30104
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 30104
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 364SC1501X
-----------------------------------------------------
Taxonomy Name | Community Health/Public Health Clinical Nurse Specialist
-----------------------------------------------------
License Number | 207581
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 364SL0600X
-----------------------------------------------------
Taxonomy Name | Long-Term Care Clinical Nurse Specialist
-----------------------------------------------------
License Number | 207581
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 363LP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Nurse Practitioner
-----------------------------------------------------
License Number | 5021996
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------