Healthcare Provider Details

I. General information

NPI: 1871358739
Provider Name (Legal Business Name): MEAGAN BLACK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/19/2024
Last Update Date: 02/19/2024
Certification Date: 02/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1121 JACKSON ST NE STE 100
MINNEAPOLIS MN
55413-3051
US

IV. Provider business mailing address

1854 BEEBE RD APT 308
MAPLEWOOD MN
55109-4828
US

V. Phone/Fax

Practice location:
  • Phone: 612-353-6293
  • Fax: 612-353-6437
Mailing address:
  • Phone: 972-670-3969
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: