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General NPI Number Information
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NPI Number | 1962009324
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Entity Type | Individual
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Provider Name | ELLIE CATHARINE BLACK FNP-C
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Gender | Female
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Dates
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Enumeration Date | 10/07/2020
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Last Update Date | 04/16/2021
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Provider Practice Location Address
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Address Line | 5265 VISTA BLVD BLDG B
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City | SPARKS
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State | NV
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Zip | 89436-0836
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Country | US
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Telephone | 775-352-5335
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Fax | 775-352-5334
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Provider Business Mailing Address
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Address Line | 2345 E PRATER WAY STE 207
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City | SPARKS
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State | NV
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Zip | 89434-9634
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Country | US
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Telephone | 775-352-5335
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Fax | 775-352-5334
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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 | 363LP2300X
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Taxonomy Name | Primary Care Nurse Practitioner
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License Number | 95014901
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 832783
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License Number State | NV
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