Provider Demographics
NPI:1407558042
Name:BLANKMAN, NICOLE (ARNP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:BLANKMAN
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:DANELLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:1414 VAN CAMP AVE SE
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32909-5656
Mailing Address - Country:US
Mailing Address - Phone:321-615-8720
Mailing Address - Fax:
Practice Address - Street 1:490 CENTRE LAKE DR NE STE 200
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32907-1189
Practice Address - Country:US
Practice Address - Phone:321-821-4950
Practice Address - Fax:321-821-4955
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-20
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11019153207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine