MEDICARE: AMY LYNN BLACK PMHNP

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	35198	TN

General Provider Information

NPI Number	:	1811750755
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMY LYNN BLACK PMHNP

Provider Business Mailing Address
First Line	:	5410 HOMBERG DR STE 22A
Second Line	:
City	:	KNOXVILLE
State	:	TN
Zip	:	37919-5029
Country	:	US
Telephone Number	:	865-269-9452
Fax Number	:	865-409-5889

Provider Business Practice Location Address
First Line	:	5410 HOMBERG DR STE 22A
Second Line	:
City	:	KNOXVILLE
State	:	TN
Zip	:	37919-5029
Country	:	US
Telephone Number	:	865-269-9452
Fax Number	:	865-409-5889

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

Provider Enumeration Date	:	02/02/2024
Last Update Date	:	02/02/2024

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