Provider Demographics
NPI:1467236877
Name:BLACKSHEEP MEDICINE LLC
Entity Type:Organization
Organization Name:BLACKSHEEP MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:WHITNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:CHARISMA
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:407-900-1394
Mailing Address - Street 1:PO BOX 522691
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32752-2691
Mailing Address - Country:US
Mailing Address - Phone:386-402-1892
Mailing Address - Fax:
Practice Address - Street 1:1120 LEXINGTON GREEN LN STE A
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771-1022
Practice Address - Country:US
Practice Address - Phone:407-900-1394
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-24
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL103694100Medicaid