Healthcare Provider Details

I. General information

NPI: 1235512468
Provider Name (Legal Business Name): SUZANNE MARIE BLACK NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2015
Last Update Date: 11/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 LEXINGTON AVE FL 2
NEW YORK NY
10075-0309
US

IV. Provider business mailing address

1120 LEXINGTON AVE FL 2
NEW YORK NY
10075-0309
US

V. Phone/Fax

Practice location:
  • Phone: 212-434-4350
  • Fax: 212-434-4408
Mailing address:
  • Phone: 212-434-4350
  • Fax: 212-434-4408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF340300
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number686557
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: