Healthcare Provider Details

I. General information

NPI: 1366623191
Provider Name (Legal Business Name): CATHERINE R BLACK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2007
Last Update Date: 03/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 RIVER PARK DR SUITE 200
PROVO UT
84604-5764
US

IV. Provider business mailing address

280 RIVER PARK DR #200
PROVO UT
84604-5764
US

V. Phone/Fax

Practice location:
  • Phone: 801-223-4860
  • Fax: 801-371-8993
Mailing address:
  • Phone: 801-223-4860
  • Fax: 801-371-8993

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number198805-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: