Basic Information
| Provider Information | |||||||||
| NPI: | 1578289369 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLACKBURN | ||||||||
| FirstName: | ELENA | ||||||||
| MiddleName: | VICTOROVNA | ||||||||
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| Credential: | SRNA, MBA, BSN, CCRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6537 FERN ST | ||||||||
| Address2: | |||||||||
| City: | NAVARRE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325668045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5096078893 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1800 ORLEANS ST | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212870010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4109555000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2022 | ||||||||
| LastUpdateDate: | 10/17/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | R253634 | MD | Y | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | R253634 | 01 | MD | RN | OTHER |