Healthcare Provider Details

I. General information

NPI: 1568777381
Provider Name (Legal Business Name): DJUANA GAIL BLACK CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2010
Last Update Date: 08/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 RUBY TYLER PKWY
TUSCALOOSA AL
35404-2958
US

IV. Provider business mailing address

1050 RUBY TYLER PKWY
TUSCALOOSA AL
35404-2958
US

V. Phone/Fax

Practice location:
  • Phone: 205-759-7246
  • Fax: 205-759-7348
Mailing address:
  • Phone: 205-759-7246
  • Fax: 205-759-7348

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1-069323
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: