MEDICARE: KAREN 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	133V00000X	Registered Dietitian	86052428	AZ

General Provider Information

NPI Number	:	1902740954
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAREN BLACK

Provider Business Mailing Address
First Line	:	15431 N 39TH ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85032-4028
Country	:	US
Telephone Number	:	480-658-9666
Fax Number	:

Provider Business Practice Location Address
First Line	:	15431 N 39TH ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85032-4028
Country	:	US
Telephone Number	:	480-658-9666
Fax Number	:

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

Provider Enumeration Date	:	04/17/2026
Last Update Date	:	04/17/2026

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