MEDICARE: SHARON SUE BLACK NP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2200X	Adult Health Nurse Practitioner	COA 11794	OH

General Provider Information

NPI Number	:	1053620096
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHARON SUE BLACK NP-C

Provider Business Mailing Address
First Line	:	2300 SR 256
Second Line	:
City	:	REYNOLDSBURG
State	:	OH
Zip	:	43068-8030
Country	:	US
Telephone Number	:	614-274-1455
Fax Number	:	614-274-2040

Provider Business Practice Location Address
First Line	:	777 W STATE ST
Second Line	:	SUITE 201 LOWER LIGHTS CHRISTIAN HEALTH CENTER
City	:	COLUMBUS
State	:	OH
Zip	:	43222-1536
Country	:	US
Telephone Number	:	614-274-1455
Fax Number	:	614-274-2040

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/24/2010
Last Update Date	:	03/01/2022

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