Healthcare Provider Details

I. General information

NPI: 1538158753
Provider Name (Legal Business Name): DAWN BLACK MSN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2005
Last Update Date: 12/27/2024
Certification Date: 12/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

228 PARK AVE S # 49409
NEW YORK NY
10003-1502
US

IV. Provider business mailing address

307 BOATNER RD STE 114
EGLIN AFB FL
32542-1302
US

V. Phone/Fax

Practice location:
  • Phone: 646-760-6669
  • Fax: 646-213-2042
Mailing address:
  • Phone: 850-883-8891
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberARNP 2747772
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: