MEDICARE: BRENDA BLACKISTON NP-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
1	363L00000X	Nurse Practitioner	LG-0000930	DE
2	363LF0000X	Family Nurse Practitioner	LG-0000930	DE

General Provider Information

NPI Number	:	1255787511
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRENDA BLACKISTON NP-C

Provider Business Mailing Address
First Line	:	101 CHESAPEAKE BLVD STE B
Second Line	:
City	:	ELKTON
State	:	MD
Zip	:	21921-6607
Country	:	US
Telephone Number	:	903-948-8566
Fax Number	:	302-633-5844

Provider Business Practice Location Address
First Line	:	401 WINSTON AVE
Second Line	:
City	:	WILMINGTON
State	:	DE
Zip	:	19804-1818
Country	:	US
Telephone Number	:	302-290-5390
Fax Number	:	302-993-1029

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/05/2016
Last Update Date	:	06/20/2024

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Directions to “ BRENDA BLACKISTON NP-C” Practice Location

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