Provider Demographics
NPI:1578289369
Name:BLACKBURN, ELENA VICTOROVNA (SRNA, MBA, BSN, CCRN)
Entity Type:Individual
Prefix:
First Name:ELENA
Middle Name:VICTOROVNA
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:SRNA, MBA, BSN, CCRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6537 FERN ST
Mailing Address - Street 2:
Mailing Address - City:NAVARRE
Mailing Address - State:FL
Mailing Address - Zip Code:32566-8045
Mailing Address - Country:US
Mailing Address - Phone:509-607-8893
Mailing Address - Fax:
Practice Address - Street 1:1800 ORLEANS ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21287-0010
Practice Address - Country:US
Practice Address - Phone:410-955-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-13
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR253634163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDR253634OtherRN