MEDICARE: CHRISTOPHER BLACK APRN

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	9152128-4405	UT

General Provider Information

NPI Number	:	1790413359
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTOPHER BLACK APRN

Provider Business Mailing Address
First Line	:	1072 E 920 N
Second Line	:
City	:	OREM
State	:	UT
Zip	:	84097-4327
Country	:	US
Telephone Number	:	801-361-2255
Fax Number	:

Provider Business Practice Location Address
First Line	:	13020 S FORT ST
Second Line	:
City	:	DRAPER
State	:	UT
Zip	:	84020-9294
Country	:	US
Telephone Number	:	801-361-2225
Fax Number	:

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

Provider Enumeration Date	:	08/11/2022
Last Update Date	:	08/11/2022

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Directions to “ CHRISTOPHER BLACK APRN” Practice Location

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