Provider Demographics
NPI:1912709965
Name:BLACKMER, FERNANDA (PTA)
Entity type:Individual
Prefix:
First Name:FERNANDA
Middle Name:
Last Name:BLACKMER
Suffix:
Gender:
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13011 LAMBRECHT RD
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-7736
Mailing Address - Country:US
Mailing Address - Phone:601-307-4454
Mailing Address - Fax:228-822-5265
Practice Address - Street 1:5502 MARVIN SHIELDS BLVD. BLDG 472
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501
Practice Address - Country:US
Practice Address - Phone:228-822-5138
Practice Address - Fax:228-822-5265
Is Sole Proprietor?:No
Enumeration Date:2025-03-27
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPTA4769225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant