MEDICARE: PHYLLIS BLACK

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
1	376K00000X	Nurse's Aide	CNA40739	FL

General Provider Information

NPI Number	:	1295950392
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PHYLLIS BLACK

Provider Business Mailing Address
First Line	:	2925 NAVAJO AVE
Second Line	:
City	:	FORT PIERCE
State	:	FL
Zip	:	34946-6740
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2925 NAVAJO AVE
Second Line	:
City	:	FORT PIERCE
State	:	FL
Zip	:	34946-6740
Country	:	US
Telephone Number	:	772-467-9439
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/16/2007
Last Update Date	:	07/08/2007

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Directions to “ PHYLLIS BLACK ” Practice Location

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