Healthcare Provider Details

I. General information

NPI: 1144465329
Provider Name (Legal Business Name): CHRISTY BLACK WILLMAN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CHRISTY MAE BLACK PT

II. Dates (important events)

Enumeration Date: 12/02/2008
Last Update Date: 12/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 W COMMONWEALTH AVE
FULLERTON CA
92832-1810
US

IV. Provider business mailing address

211 W COMMONWEALTH AVE
FULLERTON CA
92832-1810
US

V. Phone/Fax

Practice location:
  • Phone: 714-447-7000
  • Fax:
Mailing address:
  • Phone: 714-447-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number685615
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: