Provider Demographics
NPI:1033424148
Name:BLACK, AMY L (CNP)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:L
Last Name:BLACK
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 188
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:OH
Mailing Address - Zip Code:45601-0188
Mailing Address - Country:US
Mailing Address - Phone:740-773-4366
Mailing Address - Fax:740-775-7855
Practice Address - Street 1:30381 CHIEFTAIN DR
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:OH
Practice Address - Zip Code:43138-9092
Practice Address - Country:US
Practice Address - Phone:740-385-2555
Practice Address - Fax:740-380-3750
Is Sole Proprietor?:No
Enumeration Date:2010-08-12
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP-11608363LP2300X
OHRN275748- COA1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3124318Medicaid
OH3124318Medicaid