Healthcare Provider Details

I. General information

NPI: 1780944520
Provider Name (Legal Business Name): LISA ANNE BLACK ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2012
Last Update Date: 12/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 S COURTENAY PKWY SUITE B
MERRITT ISLAND FL
32952-4893
US

IV. Provider business mailing address

PO BOX 561600
ROCKLEDGE FL
32956-1600
US

V. Phone/Fax

Practice location:
  • Phone: 321-868-5815
  • Fax:
Mailing address:
  • Phone: 321-259-0635
  • Fax: 321-434-4642

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberARNP 2159422
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: