Provider Demographics
NPI:1033211842
Name:BLACK, LORA L (NP)
Entity Type:Individual
Prefix:
First Name:LORA
Middle Name:L
Last Name:BLACK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1531 ESPLANADE
Mailing Address - Street 2:ATTN: MICHELLE - FINANCE
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95926-3310
Mailing Address - Country:US
Mailing Address - Phone:530-332-7479
Mailing Address - Fax:530-893-6853
Practice Address - Street 1:888 LAKESIDE VLG COMMONS
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95928-3979
Practice Address - Country:US
Practice Address - Phone:530-332-6337
Practice Address - Fax:530-893-6936
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-02
Last Update Date:2013-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP6583363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANP6583OtherLICENSE
CANP6583OtherLICENSE
CAZZZ02951ZMedicare PIN