Healthcare Provider Details

I. General information

NPI: 1023688116
Provider Name (Legal Business Name): MEGAN KATHLEEN BLACK MSN, APRN, AGNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2021
Last Update Date: 10/02/2025
Certification Date: 10/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3404 WAKE FOREST RD
RALEIGH NC
27609-7340
US

IV. Provider business mailing address

3404 WAKE FOREST RD
RALEIGH NC
27609-7340
US

V. Phone/Fax

Practice location:
  • Phone: 919-862-5402
  • Fax: 919-954-3191
Mailing address:
  • Phone: 919-862-5402
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5014633
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number5014633
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: