Provider Demographics
NPI:1063000719
Name:BLICKHAN, BRENDA COLLEEN (AGNP-C)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:COLLEEN
Last Name:BLICKHAN
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-2834
Mailing Address - Country:US
Mailing Address - Phone:217-228-5521
Mailing Address - Fax:217-223-8231
Practice Address - Street 1:927 BROADWAY ST STE 106
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-2728
Practice Address - Country:US
Practice Address - Phone:217-223-8400
Practice Address - Fax:217-277-3974
Is Sole Proprietor?:No
Enumeration Date:2021-01-07
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020011108363L00000X
IL209.020987363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner