Healthcare Provider Details

I. General information

NPI: 1194041053
Provider Name (Legal Business Name): MS. JEANNE MARIE BLACK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2010
Last Update Date: 04/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7151 RICHMOND RD SUITE 401
WILLIAMSBURG VA
23188-7234
US

IV. Provider business mailing address

PO BOX 801
TOANO VA
23168-0801
US

V. Phone/Fax

Practice location:
  • Phone: 757-565-1700
  • Fax: 757-565-6068
Mailing address:
  • Phone: 757-565-1700
  • Fax: 757-565-6068

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number0017000296
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: