=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538158753
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAWN BLACK MSN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/20/2005
-----------------------------------------------------
Last Update Date | 12/27/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 228 PARK AVE S # 49409
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10003-1502
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-760-6669
-----------------------------------------------------
Fax | 646-213-2042
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 307 BOATNER RD STE 114
-----------------------------------------------------
City | EGLIN AFB
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32542-1302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-883-8891
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LW0102X
-----------------------------------------------------
Taxonomy Name | Women's Health Nurse Practitioner
-----------------------------------------------------
License Number | ARNP 2747772
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------