Healthcare Provider Details

I. General information

NPI: 1821904830
Provider Name (Legal Business Name): EMILY LAUREN BLACK PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2026
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2415 MCCALLIE AVE
CHATTANOOGA TN
37404-3322
US

IV. Provider business mailing address

2415 MCCALLIE AVE
CHATTANOOGA TN
37404-3322
US

V. Phone/Fax

Practice location:
  • Phone: 423-624-2696
  • Fax:
Mailing address:
  • Phone: 423-624-2696
  • Fax: 423-622-6249

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number7418
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: