Provider Demographics
NPI:1548331390
Name:BLACKMAN-COCKRAN, JUDITH (APRN)
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:
Last Name:BLACKMAN-COCKRAN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:MRS
Other - First Name:JUDITH
Other - Middle Name:A
Other - Last Name:BLACKMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CPNP
Mailing Address - Street 1:495 GOLD STAR HWY
Mailing Address - Street 2:SUITE 120
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-6228
Mailing Address - Country:US
Mailing Address - Phone:860-449-8882
Mailing Address - Fax:860-449-9195
Practice Address - Street 1:495 GOLD STAR HWY
Practice Address - Street 2:SUITE 120
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-6228
Practice Address - Country:US
Practice Address - Phone:860-449-8882
Practice Address - Fax:860-449-9195
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001870363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
2V4030OtherHEALTH NET
101870OtherCONNECTICARE
CT004238235Medicaid