Healthcare Provider Details

I. General information

NPI: 1144632217
Provider Name (Legal Business Name): SOUSAN YAZDI BLACK APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SOUSAN AKHAVAN YAZDI

II. Dates (important events)

Enumeration Date: 05/23/2014
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6420 W NEWBERRY RD STE 100
GAINESVILLE FL
32605-6622
US

IV. Provider business mailing address

PO BOX 102222
ATLANTA GA
30368-2222
US

V. Phone/Fax

Practice location:
  • Phone: 352-332-3900
  • Fax: 352-332-5009
Mailing address:
  • Phone: 239-274-8200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN9293083
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: