Provider Demographics
NPI:1700439213
Name:BLANDA, LAURA ELLEN WIMSATT (DNP)
Entity type:Individual
Prefix:DR
First Name:LAURA
Middle Name:ELLEN WIMSATT
Last Name:BLANDA
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 SAN CARLOS AVE
Mailing Address - Street 2:
Mailing Address - City:GULF BREEZE
Mailing Address - State:FL
Mailing Address - Zip Code:32561-4145
Mailing Address - Country:US
Mailing Address - Phone:504-430-8762
Mailing Address - Fax:
Practice Address - Street 1:5151 N 9TH AVE
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-8721
Practice Address - Country:US
Practice Address - Phone:850-416-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-23
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA206765367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered