Healthcare Provider Details

I. General information

NPI: 1033424148
Provider Name (Legal Business Name): AMY L BLACK CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2010
Last Update Date: 11/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30381 CHIEFTAIN DR
LOGAN OH
43138-9092
US

IV. Provider business mailing address

PO BOX 188
CHILLICOTHEE OH
45601-0188
US

V. Phone/Fax

Practice location:
  • Phone: 740-385-2555
  • Fax: 740-380-3750
Mailing address:
  • Phone: 740-773-4366
  • Fax: 740-775-7855

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberNP-11608
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN275748- COA1
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: