Healthcare Provider Details

I. General information

NPI: 1053221986
Provider Name (Legal Business Name): SONJI BLACK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2026
Last Update Date: 09/12/2026
Certification Date: 09/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11503 E 63RD ST
RAYTOWN MO
64133-5431
US

IV. Provider business mailing address

PO BOX 18233
RAYTOWN MO
64133-8233
US

V. Phone/Fax

Practice location:
  • Phone: 816-803-0512
  • Fax:
Mailing address:
  • Phone: 816-803-0512
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2018025055
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: