Healthcare Provider Details

I. General information

NPI: 1740296516
Provider Name (Legal Business Name): FREDA ANN BLACK NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 09/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 W JEFFERSON BLVD
SOUTH BEND IN
46601-1923
US

IV. Provider business mailing address

112 W JEFFERSON BLVD
SOUTH BEND IN
46601-1923
US

V. Phone/Fax

Practice location:
  • Phone: 574-546-1900
  • Fax: 574-546-1999
Mailing address:
  • Phone: 574-546-1900
  • Fax: 574-546-1999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number209.005685
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number71001497
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: