Provider Demographics
NPI:1033662242
Name:BLACK, LATISHA (APRN)
Entity Type:Individual
Prefix:
First Name:LATISHA
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:LATISHA
Other - Middle Name:
Other - Last Name:BLACK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NURSE PRACTITIONER
Mailing Address - Street 1:810 N 107TH AVE APT 301
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68114-2042
Mailing Address - Country:US
Mailing Address - Phone:402-612-1856
Mailing Address - Fax:
Practice Address - Street 1:810 N 107TH AVE APT 301
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-2042
Practice Address - Country:US
Practice Address - Phone:402-612-1856
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-25
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE56246163W00000X
NE112100363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No163W00000XNursing Service ProvidersRegistered Nurse