Healthcare Provider Details

I. General information

NPI: 1750999470
Provider Name (Legal Business Name): MELANIE ANNE BLACK AGNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2020
Last Update Date: 05/06/2025
Certification Date: 05/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2165 NW SHEVLIN PARK RD
BEND OR
97703-7101
US

IV. Provider business mailing address

PO BOX 1517
PENDLETON OR
97801-0410
US

V. Phone/Fax

Practice location:
  • Phone: 541-389-7741
  • Fax:
Mailing address:
  • Phone: 877-708-1119
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number101.0134595
License Number StateVT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: