MEDICARE: MIRANDA A BLACK LPN

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	164W00000X	Licensed Practical Nurse	PN5169477	FL
2	163W00000X	Registered Nurse	9674808	FL

General Provider Information

NPI Number	:	1518703933
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIRANDA A BLACK LPN

Provider Business Mailing Address
First Line	:	1985 W 30TH ST
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32209-3787
Country	:	US
Telephone Number	:	904-466-7339
Fax Number	:

Provider Business Practice Location Address
First Line	:	2230 PHOENIX AVE
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32206-3159
Country	:	US
Telephone Number	:	904-466-7339
Fax Number	:

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

Provider Enumeration Date	:	07/04/2024
Last Update Date	:	05/19/2025

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