Healthcare Provider Details

I. General information

NPI: 1497086219
Provider Name (Legal Business Name): LISA LYNN BLACK LM,CPM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2010
Last Update Date: 01/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3917 HICKORY BEND TRL
MCKINNEY TX
75071-2776
US

IV. Provider business mailing address

3917 HICKORY BEND TRL
MCKINNEY TX
75071-2776
US

V. Phone/Fax

Practice location:
  • Phone: 214-394-5687
  • Fax: 972-562-5174
Mailing address:
  • Phone: 214-394-5687
  • Fax: 972-562-5174

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number02008
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: