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NPI Code Detail

MEDICARE: BRENDA COLLEEN BLICKHAN AGNP-C

MEDICARE: BRENDA COLLEEN BLICKHAN AGNP-C
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363LA2200XAdult Health Nurse Practitioner209.020987IL
2363LA2200XAdult Health Nurse Practitioner2020011108MO

General Provider Information

NPI Number : 1063000719
Entity Type Code : Individual
Provider Name (Legal Business Name) : BRENDA COLLEEN BLICKHAN AGNP-C
Provider Business Mailing Address
First Line : 1005 BROADWAY ST
Second Line :
City : QUINCY
State : IL
Zip : 62301-2834
Country : US
Telephone Number : 217-223-1200
Fax Number :
Provider Business Practice Location Address
First Line : 1005 BROADWAY ST
Second Line :
City : QUINCY
State : IL
Zip : 62301-2834
Country : US
Telephone Number : 217-223-1200
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/07/2021
Last Update Date : 01/12/2026

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