Basic Information
| Provider Information | |||||||||
| NPI: | 1609857572 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLACKWOOD | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | CRNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4508 CHESTNUT ST | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191393608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155733632 | ||||||||
| FaxNumber: | 2155735602 | ||||||||
| Practice Location | |||||||||
| Address1: | 1107 E BALTIMORE PIKE | ||||||||
| Address2: | |||||||||
| City: | KENNETT SQUARE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193482366 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6103885500 | ||||||||
| FaxNumber: | 4842590200 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2005 | ||||||||
| LastUpdateDate: | 01/25/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | SP001723H | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.