Provider Demographics
NPI:1083902316
Name:BLACK, MICHELLE M (CRNP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:M
Last Name:BLACK
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 RADNOR RD STE 100
Mailing Address - Street 2:
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16801-7970
Mailing Address - Country:US
Mailing Address - Phone:814-231-7868
Mailing Address - Fax:814-238-4169
Practice Address - Street 1:120 RADNOR RD STE 100
Practice Address - Street 2:
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16801
Practice Address - Country:US
Practice Address - Phone:814-231-7868
Practice Address - Fax:814-238-4169
Is Sole Proprietor?:No
Enumeration Date:2011-07-20
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP011489363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health