Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LC1500X | Nurse Practitioner - Community Health | 23340 | SC |
NPI | 1053954438 |
---|---|
Provider Name | Andrea Blakeman |
First Address | Fort Mill, SC 29715-7037 |
Second Address | Rock Hill, SC 29730-5776 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 18/10/2019 |
Last Update Date | 01/05/2020 |