Healthcare Provider Details

I. General information

NPI: 1023355765
Provider Name (Legal Business Name): DIANNE M. BLACK DNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2013
Last Update Date: 12/05/2024
Certification Date: 12/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

593 EDDY ST CLAVERICK 2
PROVIDENCE RI
02903-4923
US

IV. Provider business mailing address

PO BOX 9484
PROVIDENCE RI
02940-9484
US

V. Phone/Fax

Practice location:
  • Phone: 401-444-4000
  • Fax:
Mailing address:
  • Phone: 401-854-2500
  • Fax: 401-854-2519

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberNPP37734
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN01118
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: