Provider Demographics
NPI:1063446367
Name:BLACK, RUTH CLAIRE (MSN, ANP)
Entity Type:Individual
Prefix:
First Name:RUTH
Middle Name:CLAIRE
Last Name:BLACK
Suffix:
Gender:F
Credentials:MSN, ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 N SHILOH RD
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75042-5716
Mailing Address - Country:US
Mailing Address - Phone:972-487-5444
Mailing Address - Fax:972-485-3056
Practice Address - Street 1:800 N SHILOH RD
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75042-5716
Practice Address - Country:US
Practice Address - Phone:972-487-5444
Practice Address - Fax:972-485-3056
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX519697364SM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SM0705XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistMedical-Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX143931702Medicaid
TX143931702Medicaid
TX81N202Medicare PIN