Provider Demographics
NPI:1235398074
Name:BLACKMON, BRENDA WOMACK (RN)
Entity Type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:WOMACK
Last Name:BLACKMON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:300 W HOSPITAL ROAD 11C17 EAMC
Mailing Address - Street 2:ATTN OFFICE OF GRADUATE MEDICAL EDUCATION
Mailing Address - City:FORT GORDON
Mailing Address - State:GA
Mailing Address - Zip Code:30905-5650
Mailing Address - Country:US
Mailing Address - Phone:706-787-4657
Mailing Address - Fax:706-787-1745
Practice Address - Street 1:300 W HOSPITAL ROAD 11C17 EAMC
Practice Address - Street 2:ATTN OFFICE OF GRADUATE MEDICAL EDUCATION
Practice Address - City:FORT GORDON
Practice Address - State:GA
Practice Address - Zip Code:30905-5650
Practice Address - Country:US
Practice Address - Phone:706-787-4657
Practice Address - Fax:706-787-1745
Is Sole Proprietor?:No
Enumeration Date:2008-06-06
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GARN141115163WM0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0102XNursing Service ProvidersRegistered NurseMaternal Newborn