Healthcare Provider Details

I. General information

NPI: 1447850458
Provider Name (Legal Business Name): HEATHER BLACK DNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2020
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 LUMBERTON AVE
CAROLINA BEACH NC
28428-4846
US

IV. Provider business mailing address

201 LUMBERTON AVE
CAROLINA BEACH NC
28428-4846
US

V. Phone/Fax

Practice location:
  • Phone: 910-543-3558
  • Fax: 910-400-2095
Mailing address:
  • Phone: 910-543-3558
  • Fax: 910-400-2095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number5013805
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: