Provider Demographics
NPI:1396029187
Name:BLACKMAN, ANGELA PAYNE (ACNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:PAYNE
Last Name:BLACKMAN
Suffix:
Gender:F
Credentials:ACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 FAIRWAY DR STE 300
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33441-1824
Mailing Address - Country:US
Mailing Address - Phone:321-434-1771
Mailing Address - Fax:
Practice Address - Street 1:1350 HICKORY ST
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3224
Practice Address - Country:US
Practice Address - Phone:321-434-1771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-28
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAL138707363L00000X
VA0024169643363L00000X, 363LA2100X
FLARNP9358792363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL100559200Medicaid
FLNJ493OtherMEDICARE HF
FLIZ355ZOtherMEDICARE