Healthcare Provider Details

I. General information

NPI: 1578556833
Provider Name (Legal Business Name): ELIZABETH LEFFT BLACK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ELIZABETH NICOLE BLACK MD

II. Dates (important events)

Enumeration Date: 08/23/2005
Last Update Date: 03/06/2023
Certification Date: 03/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1271 HIGHLAND AVE STE B
CLARKSTON WA
99403-2846
US

IV. Provider business mailing address

1271 HIGHLAND AVE STE B
CLARKSTON WA
99403-2846
US

V. Phone/Fax

Practice location:
  • Phone: 509-751-5500
  • Fax: 509-751-1059
Mailing address:
  • Phone: 509-751-5500
  • Fax: 509-751-1059

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM9634
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD00045393
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: