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General NPI Number Information
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NPI Number | 1215790274
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Entity Type | Individual
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Provider Name | MAKENNA BLACK
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Gender | Female
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Dates
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Enumeration Date | 02/02/2024
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Last Update Date | 02/02/2024
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Provider Practice Location Address
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Address Line | 1930 ALCOA HWY STE 145
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City | KNOXVILLE
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State | TN
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Zip | 37920-1546
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Country | US
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Telephone | 865-305-9749
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Fax |
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Provider Business Mailing Address
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Address Line | 7216 HALLBROOK RD
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City | KNOXVILLE
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State | TN
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Zip | 37918-9419
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0200X
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Taxonomy Name | Pediatric Nurse Practitioner
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License Number | 35631
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License Number State | TN
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