Provider Demographics
NPI:1093127623
Name:BLACKWOOD, BRANDY
Entity Type:Individual
Prefix:
First Name:BRANDY
Middle Name:
Last Name:BLACKWOOD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6100 BLUE LAGOON DR
Mailing Address - Street 2:SUITE 400
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-2079
Mailing Address - Country:US
Mailing Address - Phone:305-398-6100
Mailing Address - Fax:
Practice Address - Street 1:3800 W FLAGLER ST
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33134-1604
Practice Address - Country:US
Practice Address - Phone:305-774-3626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-02
Last Update Date:2014-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPN5208968164W00000X
FLCNA142318376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No376K00000XNursing Service Related ProvidersNurse's Aide