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NPI Code Detail

MEDICARE: HOLLY BRONSON BLACK CPNP

MEDICARE: HOLLY BRONSON BLACK CPNP
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363LP0200XPediatric Nurse Practitioner628292TX

General Provider Information

NPI Number : 1194941450
Entity Type Code : Individual
Provider Name (Legal Business Name) : HOLLY BRONSON BLACK CPNP
Provider Business Mailing Address
First Line : 600 JEFFERSON ST STE 404
Second Line :
City : LAFAYETTE
State : LA
Zip : 70501-6991
Country : US
Telephone Number : 281-346-0018
Fax Number : 281-346-0913
Provider Business Practice Location Address
First Line : 7629 TIKI DR
Second Line :
City : FULSHEAR
State : TX
Zip : 77441-1548
Country : US
Telephone Number : 281-398-7353
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/17/2007
Last Update Date : 03/30/2022

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