Healthcare Provider Details

I. General information

NPI: 1891194353
Provider Name (Legal Business Name): COUNTY OF BLACK HAWK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2014
Last Update Date: 02/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1407 INDEPENDENCE AVE FL 5
WATERLOO IA
50703-4396
US

IV. Provider business mailing address

1407 INDEPENDENCE AVE FL 5
WATERLOO IA
50703-4396
US

V. Phone/Fax

Practice location:
  • Phone: 319-291-2413
  • Fax: 319-291-2418
Mailing address:
  • Phone: 319-291-2413
  • Fax: 319-291-2418

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. NAFISSA CISSE EGBUONYE
Title or Position: DIRECTOR
Credential:
Phone: 319-291-2413