MEDICARE: MARY ELIZABETH BLACK APRN, 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	363LF0000X	Family Nurse Practitioner	A005463	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	5DK30	OTHER	AR	BCBS

General Provider Information

NPI Number	:	1679051668
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY ELIZABETH BLACK APRN, NP-C

Provider Business Mailing Address
First Line	:	175 VOLUNTEER PKWY
Second Line	:
City	:	CLINTON
State	:	AR
Zip	:	72031-8001
Country	:	US
Telephone Number	:	501-745-3388
Fax Number	:	501-745-3006

Provider Business Practice Location Address
First Line	:	175 VOLUNTEER PKWY
Second Line	:
City	:	CLINTON
State	:	AR
Zip	:	72031-8001
Country	:	US
Telephone Number	:	501-745-3388
Fax Number	:	501-745-3006

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

Provider Enumeration Date	:	08/01/2018
Last Update Date	:	06/07/2026

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