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General NPI Number Information
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NPI Number | 1912709965
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Entity Type | Individual
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Provider Name | FERNANDA BLACKMER PTA
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Gender | Female
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Dates
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Enumeration Date | 03/27/2025
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Last Update Date | 03/27/2025
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Provider Practice Location Address
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Address Line | 5502 MARVIN SHIELDS BLVD. BLDG 472
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City | GULFPORT
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State | MS
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Zip | 39501
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Country | US
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Telephone | 228-822-5138
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Fax | 228-822-5265
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Provider Business Mailing Address
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Address Line | 13011 LAMBRECHT RD
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City | GULFPORT
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State | MS
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Zip | 39503-7736
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Country | US
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Telephone | 601-307-4454
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Fax | 228-822-5265
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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 | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | PTA4769
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License Number State | MS
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