Healthcare Provider Details

I. General information

NPI: 1417938416
Provider Name (Legal Business Name): JEAN MARIE BLACK N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2005
Last Update Date: 05/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 CHRISTIANSBURG PIKE
FLOYD VA
24091-3742
US

IV. Provider business mailing address

140 CHRISTIANSBURG PIKE
FLOYD VA
24091-3742
US

V. Phone/Fax

Practice location:
  • Phone: 540-745-9290
  • Fax: 540-745-9294
Mailing address:
  • Phone: 540-745-9290
  • Fax: 540-745-9294

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024101703
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: